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RA971  C64  1918       A  study  in  hospital 


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A  STUDY   IN 
HOSPITAL  EFFICIENCY/ 

As  Demonstrated  hy  the  Case  Report 

of  the  First  Five  Years  of 

a  Private  Hospital 


1,* 


T!  ' 


BY 
E.  A.  CODMAN,  M.D. 


THE    FOREWORD    OF    THIS    EEPORT    IS 
THE    LAST    \VORT)    OF    THE    LAST    REPORT 


It  is  Idle  to  Consider  the  Standardization  of  Hospitals 
without  considering  the  Standard  of  the  Product  of  each 
Hospital,  the  part  which  the  Professional  Staff  plays  in 
raising  the  Standard  of  the  Product,  and  tJie  Compensa- 
tion which  the  Hospital  grants  the  Staff  in  return  for 
their  services. 

This  Hospital  has  for  sale  a  Product  of  the  Standard 
found  on  pages  V2—63.  It  aims  to  he  a  Hundred  Dollow 
Hospital  with  a  Hundred  Dollar  Surgeon. 


m 

97/ 


Thxs  Volume  is  Dedicated  to 
RICHARD  C.  CABOT 

BECAUSE    I    RESPECT    HIS  MOTIVES,   ADMIEE  HIS  COURAGE  AND  ENERGY, 

BUT    HEARTILY   DISAPPROVE   OF    SOME    OF   HIS   OPINIONS  AND   METHODS, 

FOR   HE   SEEMS  TO   WANT  TO  REFORM  THE  BOTTOM  OF  THE 

PROFESSION,    WHILE    I    THINK   THE    BLAME 

BELONGS    AT    THE    TOP. 


>^ 


^^^ 

^ 

^ 
^ 


PART  I 
THE   CASE   REPORT 

A  PRACTICAL  ILLUSTRATION  OF  THE  FACT  THAT  IT 

IS  POSSIBLE  TO  USE  THE  END  RESULT  SYSTEM 

IN  A  HOSPITAL 

PAGE 

Introduction            ........  6 

Quotation  from  Previous  Report           ....  8 

Abstracts  of  Cases  for  Five  Years       ....  12 

The     Advantages    of    the    End     Result    System    to 

Surgical  Science     .......  64 

Essential  Steps  in  the  End  Result  System  for  the 

Use  of  Cards  and  Chart  ......  71 

The  Chart Loose  leaf 

The  Chart  in  Print 77 

The  Educational  Factor  in   Placing  the   Diagnoses 

on  the  Chart           .......  78 

Working  for  This  Generation  or  for  the  Next  .          .  86 

The  Ownership  of  Hospital  Cases          ....  87 

Rare  Cases      .........  89 

Routine   Cases 90 

Standards         .........  91 

Our  Contribution  to  the  Cancer  Problem   ...  94 

Authority        .....••••  96 

Statistics  and  Experience 96 

Analysis  of  Our  Total  Errors  in  Five  Years  with  a 

View  to  Future  Improvement         ....  98 


PART  I 

THE   CASE   REPORT 

A  PRACTICAL  ILLUSTRATION  OF  THE  FACT  THAT  IT 

IS  POSSIBLE  TO  USE  THE  END  RESULT  SYSTEM 

IN  A  HOSPITAL 

INTRODUCTION 

The  argument  in  our  previous  Reports  has  been  somewhat  as 
follows : 

That  the  Trustees  of  our  Charitable  Hospitals  do  not  consider 
it  their  duty  to  see  that  good  results  are  obtained  in  the  treatment  of 
their  patients.  They  see  to  it  that  their  financial  accounts  are  audited, 
but  they  take  no  inventory  of  the  Product  for  which  their  money  is 
expended.  Since  the  Product  is  given  away,  they  do  not  bother  to 
standardize  it  and  to  see  whether  it  is  good  enough  to  be  sold. 

It  is  against  the  individual  interests  of  the  medical  and  surgical 
staffs  of  hospitals  to  follow  up,  compare,  analyze,  and  standardize 
all  their  results,  because: 

1.  It  is  seldom  that  any  single  individual's  results  have  been  so 
strikingly  better  than  those  of  his  colleagues,  that  he  would  desire 
such  comparison  and  analysis.  Perhaps  the  results  as  a  whole  would 
not  be  good  enough  to  impress  the  public  very  favorably. 

2.  An  effort  to  thus  analyze  is  difficult,  time-consuming,  and 
troublesome,  and  would  lead,  by  pointing  out  lines  for  improvement, 
to  much  onerous  committee  work  by  members  of  the  staff  that  would 
be  still  more  time-consuming,  difficult,  and  troublesome. 

3.  Neither  Trustees  of  Hospitals  nor  the  Public  are  as  yet  will- 
ing to  pay  for  this  kind  of  work. 

Although  the  staff  would  admit  that  such  follow-up  and  analysis 
was  a  good  thing  for  all,  yet  each  "practical"  man  (and  the  prac- 
tical men  always  hold  the  power)  would  wait  for  somebody  else  to 
do  the  work. 

The  superintendent  would  lose  his  position,  if  he  undertook  to 
insist  on  "good  results."  It  is  already  more  than  he  can  do  to  listen 
to  the  wails  of  "lack  of  economy,"  "lack  of  politeness,"  "lack  of 
common  sense"  with  which  the  trustees,  staff,  and  patients  deafen 
him. 

6 


Therefore,  if  the  trustees,  the  staff,  and  the  superintendent  all 
avoid  the  analysis  of  results,  ajid  it  is  only  for  the  interest  of  the 
patients,  the  public,  and  medical  science,  —  why  bother  about  it? 

The  truth  is,  the  patients  and  the  public  do  not  yet  understand 
the  problem.  They  suppose  that  of  course  somebody  is  looking  into 
this  important  matter.  They  do  not  realize  that  the  responsibility 
is  not  fixed  upon  any  person  or  department. 

As  for  Medical  Science's  not  caring, — this  is  the  consequence 
of  our  medical  scliools'  paying  their  teachers  by  giving  them  the 
opportunity  to  advertise.  Our  method  of  teaching  medical  science 
is  as  fraught  with  evil  as  if  our  Professors  of  Chemistry  were  per- 
mitted to  organize  a  monopoly  of  the  Trade  in  Chemicals,  so  as  to 
illustrate  to  their  students  the  "practice"  of  chemistry.  As  unpaid 
or  partially  paid  medical  teaching  is  the  custom  in  most  parts  of  the 
world,  we  have  become  used  to  it.  If  the  professors  advertised  only 
the  goods  they  actually  could  deliver,  such  a  practice  would  be  de- 
fensible ;  but  it  is  a  rare  teacher  who  can  avoid  the  assumption  of 
knowledge  which  he  does  not  possess,  as  this  is  the  time-honored 
habit  of  our  profession. 

We  have  not  offered  this  destructive  criticism  without  a  con- 
structive remedy: 

THE  END  RESULT  SYSTEM 

We  have  advocated  a  simple  system  of  hospital  organization  first 
recommended  by  the  Committee  on  Standardization  of  Hospitals 
of  the  Clinical  Congress  of  Surgeons. 

In  brief,  it  is  this: 

That  the  Trustees  of  Hospitals  should  see  to  it  that  an  effort 
is  made  to  follow  up  each  patient  they  treat,  long  enough  to  deter- 
mine whether  the  treatment  given  has  permanently  relieved  the 
condition  or  symptoms  complained  of. 

That  they  should  give  the  members  of  the  Staff  credit  for  taking 
the  responsibility  of  successful  treatment  and  promote  them  accord- 
ingly. Likewise  they  should  see  that  all  cases  in  which  the  treat- 
ment is  found  to  have  been  unsuccessful  or  unsatisfactory  are  care- 
fully analyzed,  in  order  to  fix  the  responsibility  for  failure  on: 

1.  The  physician  or  surgeon  responsible  for  the  treatment. 

2.  The  organization  carrying  out  the  detail  of  the  treatment. 

3.  The  disease  or  condition  of  the  patient. 

4.  The  personal  or  social  conditions  preventing  the  cooperation 

of  the  patient. 

This  will  give  a  definite  basis  on  which  to  make  effort  at  improve- 
ment. 


Technically^  to  start  this  System  in  a  hospital,  it  is  necessary 
to  introduce  the  use  of  an  "End  Result  Card"  which  is  kept  for  each 
patient,  and  on  which  is  recorded  in  the  briefest  possible  terms 
(see  pages  72-73)  : 

The  symptoms  or  conditions  for  which  he  seeks  relief. 
The  diagnosis  of  the  pathologic  conditions  which  the  doctor  who 
gives  the  treatment  believes  to  be  the  cause  of  the  symptoms, 
and  on  which  he  bases  his  treatment. 
The  general  plan  or  important  points  of  the  treatment  given. 
The   complications  which  followed  before  the  patient  left  the 

hospital. 
The  diagnosis  which  proved  correct  or  final  at  discharge. 
The  resiilt  each  year  afterward. 

Obviously,  the  number  of  details  given  under  these  headings 
might  be  infinite  in  extent,  but  still  no  case  is  so  complex,  that  it 
cannot  be  reduced  to  an  abstract  referring  to  a  detailed  record.  To 
take  two  extremes: 

A  simple  case  of  appendicitis  may  be  abstracted  thus: 
Came  for  the  relief  of:   acute  abdominal  pain  for  24  hours. 
Diagnosis  on  which  treatment  was  based:    acute  appendicitis. 
Important  points   of  treatment:  a  gangrenous   appendix  removed  and 
drainage  established. 
Complications :    none. 
Final  diagnosis:   acute  appendicitis. 
Result  one  year  later:  perfect. 

whereas  another  complicated  case  might  be: 

Came  for  the  relief  of:   many  ill-defined  symptoms. 

Diagnosis  on  which  treatment  was  based:  consultants  varied  in  opinions. 

Treatment:  expectant  for  4  weeks,  and  then  exploratory  laparotomy 
which  revealed  no  pathologic  conditions. 

Complications:    phlebitis,  cystitis. 

Final  diagnosis:    undetermined  except  for  phlebitis  and  cystitis. 

Result  a  year  later:   condition  the  same  as  before  treatment. 

Certainly  even  a  trustee  could  pass  the  first  case  as  O.  K.,  and 
satisfy  himself  that  the  whole  organization  of  the  hospital  did  not 
relieve  the  second. 

Undoubtedly  a  layman  could  not  enter  authoritatively  into  the 
details  of  the  reasons  why,  but  he  could  insist  that  the  End  Result 
System  should  be  used,  that  some  one  must  see  that  it  is  used; 
and  that  an  efficiency  committee  be  appointed  for  that  purpose. 

At  present,  in  most  hospitals,  no  such  investigation  is  made  by 
any  one.  There  is  no  standard  of  good  results  to  go  by,  but  we  are 
setting  standards  in  this  Report.  We  believe  they  are  as  high  as 
any.  The  questions  which  should  interest  you  are:  Are  yours  better 
or  worse.''    Are  you  making  any  effort  to  find  out? 

In  our  Charitable  Hospitals  it  is  the  Duty  of  no  person  or  Depart- 
ment to  ask  these  questions.  It  is  a  disagreeable  Duty  which  neither 
the  Staff  nor  the  Board  of  Trustees  nor  the  Superintendent  has  the 
strength  to  assume  alone.     An  Efficiency   Committee  composed  of 

7 


members  of  each  of  these  departments  should  assume  this  burden. 
The  cooperation  of  the  Board  of  Trustees  is  necessary  both  to 
authorize  the  expense  and  to  guarantee  the  standard  of  the  work 
reported. 

Even  if  a  detailed  report  is  not  published,  a  typewritten  review 
should  be  kept  for  the  use  of  the  Efficiency  Committee. 

When  this  step  is  taken  by  our  Great  Hospitals,  True  Clinical 
Science  will  begin. 

(For  thr  Benefit  of  T^iose  Readers  Who  Have  Not  Seen  the 

First  Report,  the  Following  Portion  is  Reprinted 

TO  Make  the  Ensuing  Cases  Intelligible) 

The  object  of  this  study  is  to  give  a  practical  illustration  of  the 
theory  of  hospital  organization  based  upon  an  End  Result  System. 
This  system,  with  its  simple  details,  is  set  forth  in  the  Report  of 
the  Committee  on  Standardization  of  Hospitals  presented  before  the 
Clinical  Congress  of  Surgeons  of  North  America,  at  its  meeting 
November  10-15,  1913.^    (See  also  page  71.) 

We  believe  that  all  hospitals  should  have  such  reports,  even,  and 
perhaps  especially,  private  hospitals.  We  believe  that  it  is  for  the 
private  hospitals  to  begin  this  publicity,  as  well  as  for  the  large, 
general  institutions  with  national  reputations.  The  reports  of  such 
large  institutions  would  form  minimum  standards,  and  all  private 
hospitals  and  small  non-teaching  hospitals  should  show  much  better 
results  than  the  larger  institutions. 

We  publish  this  study  to  show  that  it  is  possible  for  a  private 
hospital  to  make  such  a  report,  and  we  believe  that  if  a  private  hos- 
pital can  thus  expose  its  weaknesses,  the  public  hospitals  should 
certainly  be  able  to  do  so. 

In  the  following  Report  we  have  not  in  all  cases  attempted  to 
follow  the  letter  of  the  suggestions  of  the  above  mentioned  Commit- 
tee. If  we  had  done  so,  we  should  probably  have  had  no  readers, 
because  a  mere  set  of  abstracted  case  histories  would  have  been  too 
dull  even  for  a  statistician. 

We  want  to  have  this  report  read — partly  because  we  are  as 
proud  of  the  cases  from  a  mere  surgical  point  of  view  as  we  usually 
are  of  the  cases  reported  in  our  papers  on  special  subjects,  and 
partly  because  we  want  to  illustrate  a  definite  method  by  which  the 
organization  of  a  Surgical  Service  of  a  Hospital  can  be  based  on 
the  End  Result  System.  We  believe  the  same  general  method  can 
be  applied  to  other  branches  of  clinical  work  besides  surgery. 

The  Idea  is  so  simple  as  to  seem  childlike,  but  we  find  it  ignored 
in  all  Charitable  Hospitals,  and  very  largely  in  Private  Hospitals. 

It  is  simply  to  follow  the  natural  series  of  questions  which  any 
one  asks  in  an  individual  case: 

What  was  the  matter.'' 

Did  they  find  it  out  beforehand.'' 
^Surgery,  Oynecology,  and  Obstetrics,  January,  1914. 

8 


Did  the  patient  get  entirely  well  ? 

If  not — why  not? 

Was  it  the  fault  of  the  surgeon,  the  disease,  or  the  patient? 

What  can  we  do  to  prevent  similar  failures  in  the  future? 

We  believe  that  the  general  acceptance  of  a  system  of  hospital 
organization  based  on  the  truthful  record  of  the  answers  to  these 
questions  means  the  beginning  of  True  Clinical  Science. 

The  reader  must  not  suppose  that  we  recommend  the  publication 
of  such  criticisms  as  we  have  here  inflicted  on  ourselves,  or  even 
recommend  that  the  Chiefs  of  Surgical  Services  should  be  so  merci- 
less to  their  Juniors, 

In  this  report  we  are  proud  to  say  that  we  have  suppressed  noth- 
ing, but  have  given  even  the  smallest  details  of  lack  of  success.  We 
are  not  afraid  to  do  this,  because  we  believe  we  have  obtained  as 
good  results  in  these  cases  as  any  surgeons  could  have.  To  the  lay- 
man who  chances  to  read  this  paper,  the  fates  of  these  cases  may 
seem  far  better  or  far  worse  than  his  vague  imaginations  of  the  re- 
sults of  surgery,  but  we  believe  that  few  surgeons  would  say  that 
they  are  not  excellent.  Therefore,  why  should  not  the  layman  see 
them,  if  he  cares  to?  Why  should  he  not  look  farther  and  study  the 
reports  of  the  large  hospitals  for  himself,  to  learn  where  such  and 
such  a  branch  of  surgery  is  well  done? 

In  making  our  marginal  symbols,  with  their  accompanying  criti- 
cisms, we  have  been  hypercritical — and  in  fact  have  had  to  be,  to 
find  sufficient  illustrations  to  show  the  points  we  wish  to  make !  The 
absence  of  post-operative  complications  has  made  it  difficult  to  make 
one  of  our  chief  points  clear — that  reduction  of  the  number  of 
surgical  complications,  such  as  sepsis,  phlebitis,  cystitis,  etc.,  is  one 
of  the  easiest  ways  of  economizing  hospital  funds.  Every  patient- 
day  lost  in  a  charitable  hospital  by  these  complications  should  be 
multiplied  by  the  daily  per  capita  expense,  and  an  account  kept 
of  the  same.  This  amount  can  be  greatly  reduced  by  efficient 
organization. 

To  effect  improvement,  the  first  step  is  to  admit  and  record  the 
lack  of  perfection.  The  next  step  is  to  analyze  the  causes  of  failure 
and  to  determine  whether  these  causes  are  controllable.  We  can  then 
rationally  set  about  effecting  improvement  by  enforcing  the  control 
of  those  causes  which  we  admit  are  controllable,  and  by  directing 
study  to  methods  of  controlling  those  causes  over  which  we  now 
admit  we  have  but  little  power. 

A  hospital  that  has  an  End  Result  System,  has  an  authoritative 
method  of  admitting  and  recording  its  failures  in  diagnosis  and 
treatment. 

The  present  paper  deals  with  the  analysis  of  the  causes  of  failure 
and  the  determination  of  the  degree  within  which  we  can  control 
these  causes.  We  believe  that  the  most  difficult  step  has  been  taken 
when  the  staff  of  a  hospital  once  agrees  to  admit  and  record  the  lack 

9 


of  perfection  in  the  results  of  its  treatment.  Improvement  is  then 
sure  to  follow,  for  it  often  is  the  error  of  which  we  are  ignorant 
that  we  persist  in  carrying  with  us. 

To  illustrate  a  practical  method  of  making  such  an  analysis,  we 
have  taken  the  Results  of  our  own  private  hospital  for  the  first  two^ 
years  of  its  existence.  These  abstracts  have  been  edited  from  the 
End  Result  Cards  in  the  way  recommended.  In  a  few  of  the  more 
interesting  cases  (Cases  24,  33,  42,  53,  55,  78,  etc.)  we  have  made 
quite  a  long  abstract,  partly  to  interest  the  reader  and  partly  to  show 
that  many  cases  of  great  interest  and  importance  would  be  con- 
veniently placed  at  the  disposal  of  science  if  such  a  system  existed 
in  the  large  hospitals.  These  unusual  usual  cases,  if  we  may  so  call 
them,  are  now  lost,  because  surgeons  are  too  busy  to  write  them  up. 
The  rare  cases  of  primary  cancer  of  the  Fallopian  tube  (Case  42), 
and  the  enormous  distention  of  the  common  duct  (Case  33),  are 
unique  in  our  experience ;  but  if  we  could  skim  through  the  abstracts 
of  some  of  the  large  hospitals  we  could  no  doubt  make  collections  of 
such  cases  large  enough  for  comparative  study.  It  is  the  usualness 
of  things  which  we  think  are  unusual  which  often  keeps  us  blind  to 
important  facts  before  our  noses. 

The  reader  must  suppose  himself  the  Chief  of  a  Surgical  Service 
or  a  member  of  a  Hospital  Efficiency  Committee.  The  End  Result 
Cards  of  the  week  are  before  him.  In  a  large  hospital  the  Chief  of 
each  Service,  at  a  certain  hour,  can  have  handed  to  him  the  End 
Result  Cards  of  all  of  his  cases  which  have  been  discharged  during 
the  previous  week,  and  also  all  returns  brought  in  during  that  week 
by  the  Follow-up  System.  A  service  of  60  beds  can  thus  be  easily 
reviewed  in  one  hour  a  week.  He  must  read  them  through  and  mark 
in  the  margin  of  those  cases  which  lack  perfection  the  symbols  indi- 
cated below.  He  may  O.  K.  where  he  sees  no  flaw,  and  he  may  also 
graciously  star  the  cases  which  he  considers  creditable.  A  key  to  the 
writer's  reasons  for  criticism  will  be  found  on  pages  98-107. 

To  the  thoughtful  person  it  will  be  at  once  apparent  that  a  Chief 
of  Service  who  criticizes  the  results  of  his  juniors  or  colleagues  as 
exactingly  as  we  have  done  here  would  soon  lose  the  esprit  de  corps 
which  is  necessary  in  successful  work.  Successful  leadership  always 
requires  tact,  whether  the  driving  is  done  by  criticism  of  the  failures 
or  by  praise  of  the  successes.  To  enthusiasm  nothing  is  so  dead- 
ening as  to  be  ignored.  To  most  men  it  is  enough  to  know  that  the 
work  is  observed  and  measured,  and  if  found  of  value,  will  be 
appreciated. 

If  the  Chief  has  the  gift  of  leadership,  he  will  praise  here  and 
condemn  there,  under  any  system  of  organization ;  but  whatever  the 
gifts  of  the  Chief,  there  must  be  a  difference  in  systems,  and  it  is 
our  belief  that  an  organization  based  on  the  consideration  of  the 
actual  Results  accomplished  must  be  better  than  one  by  which  they 
are  ignored. 

'  Now  five  years. 

10 


THE  CASE  REPORT  FROM  THE  OPENING  OF  THE 
HOSPITAL  IN  AUGUST,  1911,  TO  AUGUST,  1916 

Each  patient  has  a  permanent  number — no  matter  how  many 
times  he  reenters  the  hospital.  Each  number  will  be  abstracted  once 
and  succeeding  reports  will  simply  give  the  number  and  the  state- 
ment of  the  condition  of  the  patient  at  that  date.  When  the  death 
of  the  patient  has  once  been  announced,  the  number  will  merely  be 
omitted  from  future  reports. 

Thus  far  no  case  has  been  refused  admission,  because  of  the 
gravity  of  the  condition  or  the  critical  character  of  the  operation 
involved,  although  we  by  no  means  agree  to  take  every  case. 

There  are  two  important  words  to  be  used  in  a  report  of  this  kind. 

None  —  referring  to  complications — means  that  there  literally 
were  no  complications  such  as  local  or  general  sepsis,  phlebitis, 
cystitis,  pulmonary  conditions,  burns  from  hot-water  bottles,  sinuses, 
secondary  abscesses,  or  any  other  complication  resulting  directly 
from  the  operation  or  following  it  from  other  causes. 

Well — referring  to  a  result — means  well,  except  so  far  as  in- 
evitable consequences  of  the  operation  are  concerned,  such  as  normal 
scars  in  abdominal  operations,  the  absence  of  the  limb  after  amputa- 
tion, or  the  anesthesia  inevitable  after  removal  of  the  Gasserian 
ganglion.  It  should  be  qualified  by  a  detail  if  sinuses,  hernise,  pain- 
ful scars,  or  other  troublesome  post-operative  complications  have 
occurred. 

In  the  report  of  a  charitable  hospital  the  duration  of  the  patient's 
stay  should  also  be  recorded,  because  this  item  is  important  in  the 
study  of  the  efficiency  of  the  institution.  No  patient's  stay  should  be 
prolonged  unnecessarily  in  such  institutions,  because  each  day  lost 
means  a  fraction  less  relief  given  to  some  other  patient. 


ALL  RESULTS  OF  SURGICAL  TREATMENT  WHICH  LACK 

PERFECTION  MAY  BE  EXPLAINED  BY  ONE  OR 

MORE  OF  THE  FOLLOWING  CAUSES 

Errors  due  to  lack  of  technical  knowledge  or  skill  E-s 

Errors  due  to  lack  of  surgical  judgment  E-j 

Errors  due  to  lack  of  care  or  equipment  E-c 

Errors  due  to  lack  of  diagnostic  skill  E-d 

These  are  partially  controllable  by  organization. 
The  patient's  unconquerable  disease  P-d 

The  patient's  refusal  of  treatment  P-r 

These  are  partially  controllable  by  public  education. 
The  calamities  of  surgery  or  those  accidents  and  complications 
over  which  we  have  no  known  control  C 

These  should  be  acknowledged  to  ourselves  and  to  the 
public,  and  study  directed  to  their  prevention. 

11 


In  order  to  give  readers  who  have  not  seen  the  two  previous 
Reports  the  opportunity  to  try  out  the  use  of  the  Index  Chart  and 
to  otherwise  make  the  text  more  intelligible,  I  here  repeat  abstracts 
of  those  Reports.  If  a  large  hospital  followed  this  system,  it  would, 
of  course,  only  print  the  abstracts  of  cases  which  had  entered  since 
the  last  report,  and  only  the  late  notes  of  all  cases  previously 
abstracted.  There  are  minor  errors  in  the  earlier  reports,  but  it  has 
seemed  best  to  ignore  them,  as  they  are  unimportant. 

The  only  authority  I  can  give  for  the  truthfulness  of  these 
reports  is  my  own  word.  They,  therefore,  cannot  carry  the  weight 
that  they  would  if  the  Trustees  of  an  Endowed  Hospital  had  had 
them  audited,  as  they  do  the  financial  accounts.  The  pity  of  it  is 
that  such  trustees  do  not  feel  it  their  duty  to  thus  O.  K.  the  work 
of  their  staffs.  They  content  themselves  with  hiding  behind  their 
reputations,  and  rely  on  what  the  staff  is  said  to  be  able  to  do,  not 
what  it  actually  does  do,  to  the  patients. 

I  claim  that  though  the  only  authority  I  have  for  the  accuracy 
of  these  reports  is  my  own  word,  the  publicity  discourages  decep- 
tion on  my  part.  And  I  claim  that  the  reverse  is  true  in  the  case  of 
the  Endowed  Hospitals — the  privacy  maintained  as  to  their  results 
encourages  deception. 

The  practice  of  medicine  and  surgery  will  always  be  to  a  certain 
extent  experimental.  Every  operation  done,  in  any  public  or  private 
•  hospital,  is  an  experiment.  I  do  not  claim  that  such  experiments 
are  wrong,  but  that  privacy  in  regard  to  them  is  wrong.  The  public 
is  entitled  to  know  the  results  of  the  experiments  it  must  endure. 
Both  the  successful  and  unsuccessful  experiments  and  experimenters 
should  be  advertised  (made  public).  If  charitable  hospitals  are  to 
continue  to  pay  their  staffs  only  by  the  opportunity  to  acquire 
reputation,  let  us  make  sure  that  the  reputation  is  earned.  Let  the 
hospital  do  the  advertising  of  good  and  bad  alike,  and  the  Public 
will  respond.  If  necessary,  the  hospital  itself  can  pay  for  the  pro- 
fessional care  and  study  of  cases  whose  cure  or  relief  is  so  doubtful 
that  the  "practical"  men  see  no  credit  or  profit  in  attending  them. 

Case  1.    Admitted  Aug.  25,  1911.    Male— 35.    Recurrent  attacks  of  painful 
indigestion.    Pre-operative  diagnosis — duodenal  ulcer.    Consultant — Dr. 
E-d  H.  F.  Hewes.  Op.  (E.  A.  C.)— Abdominal  exploration.  No  ulcer  found. 

Appendectomy.    Appendix  not  abnormal.    Complications — None. 
Renult:  Oct.  26,  1914 — Well.    Scar  solid.    No  pain  like  tbat  previous  to 
oi)eration,  but  in  Jan.,  1914,  an  attack  of  indigestion  soon  relieved  by 
lavage. 

2.  Aug.  28,  1911.    Female— 18.    Inability  to  breathe  through  nose.    Con't 
p,                  -Dr.  D.  Crosby  Greene.    Op.  (D.  C.  G.)— Submucous  excision  of  sep- 

tum.    Comp.— None.    July  20,  1915— Better,  but  still  annoyed  by  scabs 

on  septum. 

Result:  Aug.  3,  1916 — Condition  same. 

3.  Aug.    28,    1911.     Male — 8.     Enlarged    tonsils    and    adenoids.     Mouth 
O  K            breather.  Con't— Dr.  D.  Crosby  Greene.  Op.  (D.  C.  G.)— Tonsillectomy 

and  removal  of  adenoids.    Comp. — None. 
Result:  Aug.  3,  1916— Sister  reports,  "Well." 

12 


4.    Sept.   4,    1911.     S.    female — 41.     Double   chronic   mastitis.    Con't — Dr. 
R.  B.  Greenough.  Op.   (E.  A.  C.) — Amputation  of  both  breasts.  Comp. 
— None.    Aug.   11,  1915 — Has  since  been  operated  on  by  another  sur-    ^  ^ 
geon  for  fibroids  of  uterus.    Scars  normal. 

Result:  Sept.  12,  1916 — Well,  except  that  every  28  days  she  has  a  pain 
in  scar  of  left  breast  which  resembles  pain  she  had  before  operation. 

6.    Sept.  5,  1911.    Male — 46.    Constipation  and  pain  due  to  fissure  of  the 

anus.    Op.  (E.  A.  C.) — Stretching  of  sphincter.    Comp. — None.  O  K 

Result:  July  15,  1916— WeU. 

6.  Sept.  5,   1911.    Male— 31.    Balanitis.     Op.    (E.  A.  C.)— Circumcision. 
Comp. — None.  -.  t». 
Result:  July   17,  1915— Still  slight  eczema  on  glans.     Aug.  7,  1916—    ^  ^ 
Letter — Condition  same. 

7.  Sept.  5,  1911.    Female — 34.    Hernia  in  appendectomy  scar  from  previ- 
ous op.  by  E.  A.  C.  for  acute  appendicitis.    Recurrent  attacks  of  vomit- 
ing and  indigestion.  Op.   (E.  A.  C) — Radical  cure  of  hernia.  Comp. —    _,  . 
None.     Dec.   6,    1911,   re-entry — Fissure   in    anus.     Op.    (E.    A.    C) —       ^^ 
Stretching   sphincter,     Dec.   27,   1911,   re-entry — for   rest   and  further 
study. 

Result:  Aug.,  1913 — General  condition  much  improved.  Scar  solid.  Still 
has  distressing  attacks  of  vomiting  and  indigestion,  for  which  explora- 
tory operation  has  been  advised  but  not  urged.    Aug.  12,  1915 — Brother    P-r 
reports  "about  the  same."    Aug.  4,   1916 — Physician   reports,   "She  is 
better,  but  stiU  has  some  nausea,  and  is  more  or  less  nervous." 

8.  Sept.   14,   1911.     Male — 49.     Renal   colic  and   hematuria.     Con'ts — Dr. 
•  A.  L.  Chute  and  Dr.  F.  B.  Harrington.    Op. — Cystoscopy  and  ureteral 

catheterization  by  Dr.  Chute.    Old  blood  withdrawn  from  renal  pelvis.    E-d 

Symptoms   immediately  improved   and   disappeared  entirely  in  a  few    P-d 

days.    Explor.  op.  on  the  kidney  was  advised  but  refused. 

Result:   Died   in    May,    1913.    Autopsy — Banti's    disease   and    chronic 

nephritis. 

9.  Sept.   1,   1911.     Male — 12.     Fracture  of  both  bones  of  forearm.     Op. 

(E.  A.  C.) — Reduction  of  fragments.    Comp. — None.  O  K 

Result:  Perfect.   (Exam.  Aug.,  1912.)    July  25,  1915— Well. 

10.  Dec.  6,  1911.     Male — 84.     Hemorrhage  from  a  gangrenous  melanotic 
sarcoma  of  the  left  cheek.    Op.  (E.  A.  C.) — Cocaine.    Removal  of  sar-    p  j 
coma  and  skin  plastic  to  cover  defect.    Comp. — None. 

Result:  Died  of  recurrence  on  Mar.  7,  1912. 

11.  Dec.    12,    1911.    Male — 18.    Acute    hematogenous   infection   of    kidney 
simulating   appendicitis.    Operation   not  advised.     Con't — Dr.    Farrar 
Cobb.    No  op.  O  K 
Result:  July  19,  1915— Well.    July  28,  1916— Letter— Well. 

12.  Jan.  4,  1912.    Case  of  apoplexy  admitted  as  an  emergency  under  the 
charge  of  her  private  physician.  p_jj 
Result:  Death  on  second  day. 

13.  Jan.    17,    1912.     Female — 43.     Persistent    vomiting;    abdominal    pain; 
painful    hemorrhoids,    backache,    etc.     Op.     (E.   A.    C.) — Removal    of 
adherent  obliterated  appendix;  ventral  fixation;  clamp  and  cautery  for 
hemorrhoids;  dilatation  of  sphincter  ani.  Later  dilatation  of  oesophagus    O  K 
by  Drs.  Robinson  and  Mosher.    Comp. — None. 

Result:  Sept.  8,  1916 — Exam. — Well,  only  twinges  of  the  spasm.    Scar 
solid. 

14.  Jan.    21,    1912.    Female — 11.    Recurrent    mild    attacks    of   right-sided 

abdom.  pain.    Pre-op.  diag. — Chr.   appendicitis.    Op.   (E.   A.   C.) Re-    Q  K 

moval  of  a  strictured  appendix.    Comp. — None. 

Result:  Sept.  3,  1915— Physician  reports,  "Well." 

13 


15.  Jan.   27,   1912.     Male — 16.     Large   splinter   in   sole   of   foot   for  three 
O  K             weeks.    Op.   (E.  A.  C.) — Removal  of  splinter.    Cocaine.    Comp. — None. 

Result:  July  29,  1915— WeU. 

16.  Feb.  8,  1912.  Female — 26.  Necrotic  tuberculous  gland  of  neck;  re- 
current.   Op.  (E.  A.  C.) — Thorough  curettage. 

Result:  June,  1913 — "Well.    One  small  palpable  gland.     In  autumn  of 
1914  was  well.    May  24,  1916 — Re-entry.    Annoying  pain  in  right  iliac 
O  K  region  for  several  months.     Pre-op.  diag. — Chronic  appendicitis.     Op. 

(E.  A.  C.  and  A.  R.  B.)  Local  anaesthesia.  A  thickened  appendix  with 
concretions  and  stricture  at  the  base,  removed.  Comp. — None.  July  30, 
1916 — Letter — Well.  Jan.  4,  1917 — Re-entry.  Excision  of  painful  wart 
on  sole  of  foot.    Otherwise  well. 

17.  Feb.   10,  1912.     Female— 39.     Hemorrhoids.     Op.    (E.   A.  C.)— Clamp 
•p,  .               and  cautery.    Comp. — None. 

^^  Result:  Sept.  8,  1913 — Well,  except  for  annoyance  from  skin  tabs  which 

were  not  removed. 

18.  Feb.   11,  1912.    Female — 38.    Intermittent  right-sided  abdominal  pain 
p  J              and  one  attack  of  jaundice.    Pre-op.  diag. — Gallstones.    Op.  (E.  A.  C.) 

— No    gallstones.     Appendix    removed;    not    abnormal.     Comp. — Mild 
■p,  sepsis  in  abdom.  fat,  not  delaying  conval.    S.  albus.    Attack  malaria  in 

"*"  second  week.    Parasite  demonstrated  by  Dr.  G.  C.  Shattuck. 

Result:  July  24,  1916 — "Well.    Scar  O.K.    Minor  complaints. 

19.  Feb.  12,  1912.  Female — 49.  Abdom.  pain  and  fibroid  tumors  of  uterus. 
Op.  (E.  A.  C.) — Hysterectomy  and  appendectomy.    Ap.  strictured  and 

O  K  adherent.    Comp. — None. 

Result:  Aug.  5,  1916— Letter— Well. 

20.  Feb.  13,  1912.  Neurasthenic  female — 44.  Persistent  vomiting,  abdom. 
pain  and  low  urinary  output.    Great  improvement  under  proper  feed- 

O  K  ing  and  care  for  three  weeks. 

Result:  July  26,  1915 — Better,  "but  still  has  trouble  and  constipation." 

21.  Feb.  15,  1912.  Male — 59.  Recurrent  attacks  of  painful  indigestion  of 
many  years'  standing.  Recent  profuse  hematemesis.  Pre-op.  diag. — 
Duodenal  ulcer.    Op.   (E.  A.  C.) — Post.  gast.  ent.  and  infolding  ulcer. 

O  ^  Comp. — None. 

Result:  Aug.  4,  1915— WeU.  Aug.  5,  1916— Letter— Well.  Jan.  26,  1917 
— Well  until  within  a  few  months,  when  hj-peracidity  symptoms  re- 
turned.   Vacation  advised. 

22.  Feb.  15,  1912.    Male.    Emergency  case  of  severe  epistaxis  under  charge 
OK            of  another  phvsician. 

Result:  July  16,  1915— WeU. 

23.  Feb.  24,  1912.  Male — 59.  Comminuted  fracture  and  external  displace- 
ment of  head  of  humerus.  Removed  to  Corey  HiU  Hospital.  Op. 
(E.  A.  C.) — Excision  of  head  of  humerus  by  "sabre  cut"  incision. 
Comp. — None. 

Pj  ^  Result:    Aug.,    1913 — Excellent.     Can    play    a    good    game    of    golf. 

Aug.  23,  1916 — "Golf  handicap  17."  Useful  but  by  no  means  perfect 
shoulder.  Most  of  the  motion  is  accomplished  with  the  scapula  on  the 
chest  wall.  Somewhat  awkward  in  many  motions,  but  on  the  whole 
satisfactory. 

24.  Mar.  5,  1912.  Male — 59.  Crippled  with  infectious  arthritis  of  many 
joints  and  suffering  from  pronounced  digestive  disturbances  of  many 
years'  standing;  also  profuse  purulent  chronic  bronchitis.  Referred  by 
Dr.  C.  F.  Painter,  to  whom  he  had  applied  for  relief  from  his  arthritis. 
The  patient  was  kept  two  weeks  before  operating  in  hope  of  improv- 
ing his  general  condition,  which  was  wretched.  Con't — Dr.  R.  H.  Fitz. 
Pre-op.  diag. — Gallstones.    Op.   (E.  A.  C.) — Multiple  adhesions.    Con- 

14 


tracted  gall  bladder  containing  a  large  stone  and  connected  by  tortuous 
suppurating  sinus  with  duodenum.  Cliolecystectomy  and  drainage  of 
sinus.  Coinp. — Pneumonia  and  leakage  of  duodenal  contents  and  finally 
peritonitis. 

Result:  Lived  13  days.  This  was  a  case  of  diffuse  chronic  pneumococ- 
cus  infection  before  operation,  for  pneumococcus-like  organisms  were 
obtained  from  the  sputum  and  from  the  stomach  washings.  The  latter 
came  from  the  stomach  tube  in  the  form  of  false  membranes  resembling  p_j 
rose  leaves  in  consistency  and  color.  Under  the  microscope  these  proved 
to  be  almost  pure  masses  of  pneumococci.  At  autopsy  pure  cultures 
were  also  obtained  from  peritoneal  cavity  and  from  joints.  The  lungs 
showed  multiple  chronic  bronchiectases  and  small  areas  of  pneumonic  g_: 
consolidation.  This  case  also  illustrates  the  point  which  has  been 
brought  out  by  E.  A.  C,  that  the  reason  that  Courvoisier's  law  holds 
true  is  that  contracted  gall  bladders  in  the  presence  of  common  duct 
stone  probably  always  have  intestinal  fistulse  at  some  time.  Hence 
one  never  finds  a  contracted  gall  bladder  that  is  not  adherent  to  the 
intestine. 

25.  Mar.  7,  1912.    Female.    Under  the  care  of  Dr.  W.  P,  Graves.    Severe 
metrorrhagia.    Op.   (W.  P.  G.) — Abdom.  hysterectomy  for  uterine  in-    >-.  x, 
sufficiency.    Comp. — None. 

Result:  Aug.,  1913 — No  report. 

26.  Mar.  8,  1912.    Female.    Under  the  care  of  Dr.  W.  P.  Graves.    Op.— 
Plastics    on    cervix    and    perineum;    ventral   fixation;    appendectomy,    q  jj 
Comp. — None. 

Result:  Sept.  27,  1915— Dr.  G.  reports  O.  K. 

27.  Mar.  10,  1912.    Male— 17.    Carbuncle  of  the  upper  lip.    No  op.    Re- 
covery. O  K 
Result:  Aug.  13,  1915— Well.    No  scar. 

28.  Mar.  13,  1912.  Female — 32.  Chronic  mastitis  and  mastodynia.  Both 
nipples  had  previously  been  removed  by  another  surgeon.  Op.  (E.  A. 
C.) — Removal  of  both  breasts.    Comp. — None. 

Result:  Sept.,  1913 — Great  relief  from  the  above  op.    Now  has  distress-    O  K 
ing  abdom.  symptoms.    July  19,  1915 — Satisfactory  result,  but  patient 
has  since  had  an  abdominal  operation  by  another  surgeon.    July  27,  1916 
— Physician  reports,  "Much  better  this  past  year." 

29.  Mar.  28,  1912.  Female.  Under  the  care  of  Dr.  W.  P.  Graves.  Back- 
ache, fatigue  and  pelvic  lacerations.  Procidentia.  Op.  (W.  P.  G.) — 
Myomectomy  and  ventral  fixation.  Plastic  on  cervix  and  ant.  and  post, 
colporrhaphy.  Comp. — Secondary  hemorrhage  from  cervix  of  no  prac- 
tical importance. 

Result:  Nov.  14,  1913— Well  (physician). 

30.  Mar.  29,  1912.  Female— 16.  Separation  of  right  sacro-iliac  synchon- 
drosis from  an  automobile  accident.    Rest  in  bed  for  three  weeks. 

Result:  Sept.  9,  1915 — Well,  except  for  chronic  tonsillitis  and  chronic    q  jf 
organic  heart  disease,  which  were  present  at  time  of  accident.    Aug.  21, 
1916— Same. 

31.  Apr.  2,  1912.  Male — 45.  Acute  biliary  colic  and  chronic  indigestion. 
Pre-op.  diag.— Gallstones.  Op.  (E.  A.  C.)— Cholecystostomy  and  re- 
moval of  stones.    Comp. — None. 

Result:  Aug.  21,  1913— Well.  Slight  digestive  symptoms.  Aug.  19, 
1915 — Since  last  report  digestive  symptoms  became  worse  and  op.  was  E-s 
again  advised.  This  was  done  by  another  surgeon,  who  writes  that  the 
gall  bladder  was  removed  and  tlie  common  duct  drained.  After  this 
was  healed,  a  hernia  in  an  appendectomy  scar  was  repaired.  Later  the 
patient  had  attacks  of  abdominal  pain  with  slight  jaundice,  and  in  one 

15 


attack  passed  a  small  gallstone.  Better  since.  Aug.  1,  1916 — Looks 
well,  but  still  has  numerous  minor  complaints.  Scars  normal.  Still 
particular  about  diet.  Has  had  no  attacks  of  biliary  colic.  Has  acid 
indigestion  and  severe  headaches. 

32.  Apr.  7,  1912.  Female — 40.  Intermittent  hydro-nephrosis.  Palpable 
tumor  in  left  flank  size  child's  head.  Op.  (E.  A.  C.) — Kinking  of  ureter 
found  to  be  due  to  aberrant  vein  to  lower  pole  of  kidney.    Kinking  pre- 

O  K  vented  by  suturing  vein  to  pelvis  of  kidney.    The  vein  was  too  large  to 

be  safely  divided.    Comp. — None. 

Result:  July,  1913— Well.  Kidney  palpable,  July  29,  1916— Letter- 
Well. 

33.  Apr.  8,  1912.  Female — 29.  Deep  obstructive  jaundice  and  a  tumor 
in  epigastrium.  Pre-op.  diag. — Empj'ema  of  gall  bladder.  Op.  (E.  A. 
C.) — The  tumor  proved  to  be  an  enormously  distended  common  duct- 
28  ounces  of  bile  v/ere  aspirated  and  several  ounces  of  bile  later  sponged 
out.  The  duct  also  contained  about  2  ounces  of  muddy  material  and 
one  very  small  facetted  gallstone.  The  dilatation  extended  into  the 
hepatic  ducts,  but  the  cystic  duct  and  gall  bladder  were  of  normal  size 
and   contained   normal   bile.    Much   bleeding   at   the  operation;   oozing 

E-j  continued  from  the  wound  until  the  13th  day,  when  after  consultation 

with  Dr.  M.  H.  Richardson  and  Dr.  R.  H.  Fitz  transfusion  was  done 
by  Dr.  Beth  Vincent.  Bleeding  at  once  ceased  and  the  patient  made  a 
good  recovery,  leaving  the  hospital  on  the  54th  day  with  a  small  biliary 
sinus.  On  Aug.  8,  1912,  a  choledocho-duodenostomy  was  performed 
by  Dr.  Hugh  Williams  and  Dr.  E.  A.  Codman  at  the  Massachusetts 
General  Hospital.  Six  days  after  this  op.  typical  cholemic  bleeding 
again  occurred  to  some  extent,  but  was  controlled  by  local  packing  and 
by  injection  of  rabbit  serum,  15  c.c,  on  the  14th  day.  No  other  comp. 
Result:  Dec.  9,  1913 — Well,  but  has  had  several  attacks  of  mild  jaun- 
dice with  slight  pain.  Feb.,  1914 — Well.  Aug.  1,  1916 — Brother  reports, 
"Fairly  well."    Occasional  pain  in  region  of  scar. 

34.  Apr.  10,  1912.  Male — 44.  Inflamed  perineal  sinus  exactly  resembling 
a  pilonidal  sinus,  but  extending  anteriorly  from  the  rectum.    Op.   (E. 

OK  A.  C.) — Cocaine.    Opening  and  packing  sinus.    Comp. — None. 

Result:  Aug.  10,  1916 — Exam. — Well.  No  scar  of  sinus. 
.^•5.  Apr.  16,  1912.  Female — 37.  Vague  abdom.  discomfort,  constipation 
and  inertia.  For  diagnosis  and  X-ray.  Explor.  op.  was  advised  but 
not  urged,  under  the  diagnosis  of  ptosis  and  retroversion.  Op.  refused. 
Result:  Sept.  4,  1913 — No  improvement.  July,  1915 — Phys.  reports, 
"Patient  has  since  had  an  abdominal  operation  by  another  surgeon." 
July  28,  1916 — Writes  that  the  operation  she  had  after  leaving  this 
hospital  surely  has  been  beneficial. 

."56.  Apr.  20,  1912.  Male — 40.  Vague  abdom.  discomfort.  For  diag.  and 
X-rays.  Palpable  tumors,  evidently  tulierculous  mesenteric  glands  were 
found.  Severe  degree  of  ptosis.  The  patient,  on  hearing  that  the  chance 
of  any  relief  from  operation  was  small,  did  not  wish  to  be  operated 
upon. 
Result:  Aug.,  1913 — No  improvement.    Sept.  19,  1913 — Decided  to  take 

P-d  any  risk.    Op.  (E.  A.  C.  and  G.  W.  M.)  at  Copp  Hospital,  Cambridge. 

Removal  of   four  broken-down  tuberculous  glands  of  mesentery  near 

C  ligament  of  Treitz.    Removal  of  a  greatly  dilated  prolapsed  cecum  with 

ascending  colon  and  a  small  portion  of  ileum  and  a  stenosed  appendix. 
Acute  dilatation  of  stomach  on  3d  day,  relieved  by  repeated  lavage. 
Result:  Recovered   from  the  operation,  but  died  on  Oct.  16  of  pneu- 
monia of  six  days'  duration. 

87.    Apr.  22,  1912.     Male— 21.     Right  inguinal  hernia.     Op.   (E.  A.  C.)— 
f^  Tj.  Ferguson  method.    Comp. — None. 

^  ^  Result:  In  1916,  friend  reported,  "Well." 

16 


P-r 
E-d 


E-j 


38.  May  6,  1912.  Female— 51.  Cancer  of  right  breast.  Op.  (E.  A.  C.)— 
Amputation  and  dissection  of  axilla.  Axillary  glands  involved.  Comp. 
—None.  ^      P-d 

Result:  Dec.  1,  1913 — No  sign  of  recurrence.    Pain  in  arm.     Died  in 
summer  of  1914.    Recurrence  in  spine? 

89.    June   3,    1912.    Female — 67.    Details    the   same    as    case   38.    Comp. —    „ 
Slight  necrosis  edges  of  skin  flaps. 
Result:  Died  in  July,  1913,  of  spinal  metastasis.  P-d 

40.  June  2,  1912.    Male— 19.    Septic  olecranon  bursitis.    Op.  (E.  A.  C.) — 
Incision  and  packing  of  bursa.    Comp. — None.  O  K 
Result:  No  report. 

41.  June  6,  1912.    Female— 78.    Epithelioma  of  eyelid.    Op.  (G.  W.  M.)— 
Removal  of  growth.    Comp. — None.  O  K 
Result:  Unknown. 

42.  June  8,  1912.  Female — 54.  Recently  recovered  from  a  subacute  attack 
of  appendicitis.  During  this  attack  she  had  been  seen  in  consultation 
by  E.  A.  C.  and  conservative  treatment  advised,  because  her  symptoms 
suggested  that  some  other  serious  abdominal  condition  also  existed — 
probably  gallstones.  As  a  difficult  operation  was  to  be  avoided  if  pos- 
sible in  a  private  house,  it  was  felt  wiser  to  wait  until  the  patient  could 
come  to  Boston.  Op.  (E.  A.  C.) — The  gall  bladder  was  normal;  the 
appendix  (still  subacutely  inflamed)  was  removed.  There  were  a  few 
small  uterine  fibroids  which  were  not  removed.  The  left  tube  was  the 
size  of  a  banana  and  was  closed  at  the  fimbriated  end,  and  presented 
the  appearance  of  a  chronic  hydrops.  It  was  removed  entire  and  after 
removal  showed  on  section  a  remarkable  pedunculated  cystic  papillom- 
atous tumor.    Tlie  specimen  was  examined  by  Dr.  W.  F.  Whitney  and 

was  pronounced  a  unique  case  of  carcinoma  of  the  Fallopian  tube.  It  P-d 
is  preserved  in  the  Warren  Museum  of  the  Harvard  Medical  School. 
From  the  specimen  alone  one  would  say  that  the  possibility  of  recur- 
rence was  infinitesimal,  so  much  healthy  proximal  tissue  was  removed 
with  it;  and  yet  the  sequel  showed  a  rapid  recurrence,  for  6  months 
later  a  second  operation  was  done  by  E.  A.  C.  at  the  patient's  home 
and  a  difl'use  carcinomatosis  of  the  peritoneum  found.  The  omentum 
was  studded  with  the  same  minute  beautiful  yellow  green  and  orange 
cysts  which  characterized  the  original  tumor. 

Result:  The  patient  has  since  been  treated  by  her  physician  under  the 
direction  of  Dr.  R.  B.  Greenough  and  Dr.  E.  H.  Risley  with  cancer 
serum.  Sept.  23,  1913 — Is  still  living,  but  rapidly  failing.  Nov.  29, 
1913 — Apparent  improvement.  Able  to  be  up  (physician).  Died 
Jan.  6,  1914.    Autopsy — Diffuse  carcinomatosis. 

43.  June   8,    1912.    Emergency   case  of  hemiplegia  under  the   charge  of 
another  physician.  p.^ 
Result:  Death  on  16th  day. 

44.  June  9,  1912.    Male— 38.    Perineal  urethral  abscess.    Op.   (G.  W.  M.) 

— Incision  and  drainage.    Dilatation  of  stricture.  O  K 

Result:  Aug.  8,  1916— Dr.  M.  reports,  "Perfectly  well  May,  1916." 

46.   June  10,  1912.    Female — 54.    Bad  organic  heart  lesion.    Sought  relief 
from  recurrent  right-sided  abdominal  pain  and  digestive  disturbances. 
X-ray   examination   unexpectedly   showed   a   large   stone   in   the   right 
kidney.     The    combined    urine    was    normal.     Ureteral    catheterization    _,  . 
showed  that  both  kidneys  secreted  normal  urine.    The  pheno-sulph.  test       ^^ 
appearing  in   li  minutes  and  showing  7%  on  right  and  23%  on  left.    -, 
Op.  (E.  A.  C.) — Knowing  that  the  left  kidney  was  sound  and  believing 
as  I  do  that  one  sound  kidney  is  better  than  one  sound  one  and  one  bad 
one,  and  that  kidneys  long  blocked  by  stone  seldom  return  to  normal 

17 


showed  besides  the  large  stone  several  small  ones,  one  of  which  was 
80  buried  in  the  kidney  substance  that  it  would  not  have  been  reached 
by  pyelotomy.  The  patient  made  a  good  operative  recovery.  The  wound 
was  soundlj'  healed  and  she  was  beginning  to  sit  up,  when  on  the  19th 
day  she  suddenly  died.  No  autopsy  was  obtained,  so  it  is  uncertain 
whether  death  was  due  to  the  heart  lesion  or  to  pulmonary  embolism 
from  the  renal  vein,  probably  the  latter. 

46.  June  13,  1912.  Female — 69.  Purulent  discharge  from  the  right  nipple 
and  chronic  mastitis.  Op.  (E.  A.  C.) — Excision  of  right  breast  and 
removal  of  an  epithelioma  of  the  nose  (incidentally  discovered).  Comp. 

^  — None. 

Result:  Aug.  25,  1913— Well.  Aug.  21,  1916— Exam.— Scars  O.  K. 
General  health  good. 

47.  June  18,  1912.  Female— 22.  Dysmenorrhoea.  Op.  (E.  A.  C.)— Dila- 
tation of  cervix.    Comp. — None. 

•d  Result:  July  25,  1915 — Great  improvement.    (Letter.)    July  27,  1916 — 

Mother  writes  that  she  is  better,  but  still  has  menstrual  pain  at  times. 

48.  July   1,    1912.     Male — 6.    Constipation.     Congenital   dilatation  of  the 
zr            sigmoid.    Radioscopic  examination  and  observation.    Op.  not  advised. 

Result:  Aug.,  1913 — Somewhat  improved  by  conservative  treatment. 

49.  July  6,  1912.  Female — 29.  Marked  neurasthenia  and  subsiding  acute 
appendicitis.  Op.  (E.  A.  C.) — Appendectomy.  Ap.  subacutely  inflamed. 
Comp. — None. 

K  Result:  Sept.  20,  1913 — Greatly  improved  but  still  has  vague  abdominal 

symptoms.  Aug.  10,  1916 — Physician  writes,  "She  says  she  is  feeling 
better  than  she  has  for  years." 

50.  July  6,  1912.  Male — 35.  Typical  symptoms  of  acute  appendicitis  of 
12  hours'  duration.  Op.  (E.  A.  C.) —Gangrenous  appendicitis.  Appen- 
dectomy and  drainage.    Comp. — None. 

■s  Result:  Oct.,  1913 — Well,  except  for  small  hernia  in  scar.    July  19,  1916 

— Well.  Hernia  not  examined.  Aug.  18,  1916 — Telephone — "No  further 
symptoms." 

61.  July  8,  1912.  Female — 42.  Tumor  of  breast.  Pre-op.  diag.  in  favor 
of  fibroma.  Op.  (Dr.  C.  C.  Simmons  present  in  consultation)  (E.  A.  C.) 
— After  exploration  with  cocaine,  amputation  of  breast  and  dissection  of 
axilla  under  ether,  one  axillary  gland  involved.  Path,  report — Cancer. 
Result:  Nov.,  1913 — Well  (exam.).    A  small  cyst  in  other  breast.    Feb., 

•d  1914 — Cyst  has  entirely  disappeared.  Well.    July  16,  1915 — Under  treat- 

ment for  fracture  of  olecranon.  Aug.  5,  1916 — Exam. — Well.  Union  of 
olecranon  excellent,  but  lacks  about  45'  of  flexion.  Weight  normal. 
No  recurrence. 

62.  Aug.  3,  1912.    Female.    Lipoma  of  forearm.    Op.  (E.  A.  C.) — Excision. 
K            Comp. — None. 

Result:  No  report. 

63.  Aug.  12,  1912.  Female — 37.  Cauliflower  cancer  at  umbilicus  size  of 
fist,  infiltrating  the  adjacent  muscles  and  having  a  fecal  fistula  in  its 
center.  Pelvic  induration.  Patient  bedridden.  Operation  at  first  re- 
fused by  E.  A.  C.  on  the  ground  of  inoperability.    As  the  patient  and 

J  her  husband  begged  that  some  attempt  be  made,  even  at  great  risk,  a 

consultation  was  held  with  Drs.  C.  A.  Porter,  D.  F.  Jones  and  H.  Cabot. 
Dr.  Cabot  had  some  years  previously  successfully  removed  a  tuberculous 
stricture  from  the  patient's  rectum.  It  was  decided  to  attempt  opera- 
tion and  Dr.  Porter  consented  to  do  it.  Op.  (C.  A.  P.  and  E.  A.  C.) — 
Tiie  growth  with  an  oval  area  containing  about  one-half  the  abdominal 
wall  with  most  of  the  transverse  colon  and  omentum  were  removed 

18 


P-d 


en  masse;  end  to  end  anastomosis  of  colon.  When  this  had  been  com- 
pleted another  annular  carcinoma  of  the  sigmoid  was  found  buried  in 
pelvic  adhesions.  This  was  obviously  causing  obstruction  and  yet  could 
not  be  removed;  a  lateral  anastomosis  was  done  which  successfully 
short-circuited  it.  At  this  time  her  condition,  though  one  of  shock, 
seemed  viable  if  the  abdominal  wall  could  be  closed.  This  seemed  im- 
possible, for  the  edges  would  not  meet  by  several  inches  even  under 
tension.  Dr.  Porter  resorted  to  an  expedient  which  he  has  before  used 
but  never  published.  With  a  few  sweeps  of  his  hand  he  mobilized  the 
whole  peritoneum  back  to  the  psoas  muscle  on  each  side.  The  intestines 
were  easily  sewed  up  in  this  free  membrane  as  in  a  bag.  Over  this  the 
fascia  and  skin  were  pulled  as  far  as  possible,  but  could  bj'  no  means 
be  brought  together,  and  gauze  was  packed  down  to  the  peritoneal  bag. 
The  patient  recovered  in  spite  of  leakage  from  the  colon  anastomosis 
and  a  troublesome  fecal  fistula.  (I  have  no  hesitation  in  saying  that  this 
was  the  most  remarkable  abdominal  operation  I  have  ever  seen  which 
resulted  successfully;  nor  have  I  ever  seen  such  courage  as  this  patient 
exhibited  both  before  and  after  her  operation.) 

Result : .Sept.  1,  1913 — Her  husband  (a  doctor)  writes  that  in  spite  of 
a  troublesome  sinus  she  is  up  and  about  every  day  and  that  there  is  no 
sign  of  return  of  the  growth.   Died  in  Nov.,  1913. 

54.  Aug.  19,  1912.    Female.    Fracture  of  clavicle. 
Result:  Aug.,  1913 — Well,  but  has  considerable  bony  callus. 

55.  Aug.  23,  1912.  Female — 79.  Extensive  carcinoma  of  thyroid.  Con't 
—Dr.  C.  A.  Porter.  Op.  (C.  A.  P.  and  E.  A.  C.)— Radical  dissection. 
The  growth  had  penetrated  the  capsule  and  invaded  the  carotid  sheath. 
All  visible  malignant  tissue  was  removed.    Comp. — None. 

Result:  The  patient  left  the  hospital  with  the  wound  healed  on  the   *^"" 
15th  day.    Recurrence  was  evident  within  a  week  and  at  once  became 
fulminating.    Death  occurred  within  a  month,  at  which  time  the  re- 
current growth  was  twice  the  size  as  at  the  time  of  operation. 

56.  Sept.  1,  1912.  Female — 36.  Had  suffered  from  abdominal  pain  sugges- 
tive of  duodenal  ulcer  and  had  previously  had  an  unsuccessful  appen- 
dectomy (?)  by  another  surgeon.    Pre-op.  diag. — Peripyloric  adhesions. 

Op.  (E.  A.  C.) — Multiple  adhesions  separated  and  raw  surfaces  covered    O  K 
by  peritoneal  plastic.    Comp. — None. 
Result:  Aug.  2,  1916— Letter— Well. 

57.  Sept.  7,  1912.  Male — 4.6.  "Neuritis"  and  subacromial  bursitis.  Op. 
(E.  A.  C.) — Excision  of  a  portion  of  bursa.  Comp. — Protracted  con- 
valescence with  much  pain. 

Result:  Aug.,  1913 — Well,  except  for  occasional  twinges  in  shoulder.    E-j 
Sept.    8,  1915 — Well.    July   28,  1916 — Letter — No  inconvenience  since 
last  report.    Patient  states  that  shoulder  has  never  regained  its  normal 
size  in  spite  of  exercise. 

58.  Sept.   13,   1912.     Very  stout   male — 64.     Right   inguinal  hernia.     Op. 
(E.  A.  C.     Spinal  anaesthesia  by  Dr.  Freeman  AUen) — Radical  cure 
(Bassini).    Comp. — None.  O  K 
Result:  Aug.  28,  1913— Well.     Aug.  18,  1915— Well,  except  for  same 

chr.  cough.    July  27,  1916— Letter— Well. 

59.  Sept.  18,  1912.  Female — 58.  Constipation,  weakness,  vague  stomach 
symptoms,  and  a  very  tight  sphincter  ani.    Op.  (E.  A.  C.) — Proctoscopy 

and  stretching  sphincter.    Comp. — None.  q  ^ 

Result:  Aug.  18,  1913 — Much  relieved.  No  constipation.  Slight  hyper- 
acidity. Aug.  21,  1916 — Exam. — Much  improved,  but  still  under  treat- 
ment by  physician  for  acid  indigestion.    No  constipation. 

19 


60.  Sept.  19,  1912.  Female.  Deformed  and  painful  great  toe  nail,  previ- 
ously unsuccessfully  operated  on  by  another  surgeon.    Op.  (E.  A.  C.) 

O  K  — Removal  of  nail  and  excision  of  matrix.    Comp. — None. 

Result:  Nov.  1,  1913— Well.  April  18,  1916— No  further  trouble.  Scar 
rough  and  horny. 

61.  Oct.  11,  1912.  Female— 9.  Under  the  care  of  Dr.  Harvey  Gushing. 
Acute  internal  hydrocephalus,  complicating  an  interpeduncular  (hypo- 
piiysial)  tumor.    Op.  (H.  C.) — Callosal  puncture  and  ventricular  drain- 

p   ,  age.    Relief  of  pressure  symptoms.    Comp. — None. 

Result:  Aug.,  1913 — Condition  unchanged.  Dec,  1913 — Has  since  been 
operated  on  by  Dr.  Gushing  at  the  Brigham  Hospital.  June,  1915 — 
"Her  father  states  that  her  condition  is  about  as  a  year  ago."  Brigham 
Hospital,  No.  278  and  No.  1217.  July  31,  1916— Dr.  G.  reports,  "Con- 
dition unchanged." 

O  K      62.    Oct.  11,  1912.    See  note  on  case  125. 

Result:  July  31,  1916— Dr.  B.  reports,  "Well." 

63.  Oct.  17,  1912.  Female— 64.  Under  the  care  of  Dr.  Harvey  Gushing. 
>-j  r^            Major  trigeminal  neuralgia.    Op.   (H.  C.)   Oct.  19,  1912 — Sensory  root 

avulsion.    Comp. — None. 

Result:  July  31,  1916— Dr.  C.  reports,  "Well." 

64.  Male — 35.  Right-sided  abdominal  pain.  Pre-op.  diag. — Appendicitis. 
O  K            ^P-  (^-  ^^^'  ^^O — Appendectomy  for  subacute  appendix.    Comp. — None. 

Result:  Aug.  13,  1913— Well.  Gained  30  pounds.  Dr.  M.  reports, 
"Perfectly  well  June,  1916." 

65.  Oct.  19,  1912.  Male — 52.  Under  the  care  of  Dr.  Harvey  Gushing. 
Pituitary   struma   with   hypopituitarism    and   blindness.     Op.    (H.    G.) 

P-d  Oct.   21,   1912 — Transphenoidal   sellar  decompression   with   partial  re- 

moval of  struma.    Comp. — None. 
Result:  July  31,  1916 — Dr.  C.  reports,  "Condition  unchanged." 

66.  Oct.  22,  1912.  Male — 20.  Epilepsy.  Old  gunshot  wound  of  head  which 
p  J              had  caused   depressed  fracture  of  skull.    Gon't — Dr.  Harvey  Gushing. 

Op.  not  advised. 

Result:  Aug.,  1913 — Improved  under  bromides. 

67.  Oct.  22,  1912.  Male — 68.  Under  the  care  of  Dr.  Harvey  Gushing. 
f^  T^  Major  trigeminal  neuralgia.  Op.  (H.  G.) — Sensory  root  avulsion. 
^  ^            Coriip.- None. 

Result:  July  31,  1916— Dr.  G.  reports,  "Well." 

68.  Oct.  23,  1912.  Male — 43.  Pain,  constipation  and  palpable  rectal  tumor. 
Pre-op.  diag. — Cancer  of  rectum.  Gon't — Dr.  D.  F.  Jones.  Op.  (E.  A. 
G.) — Exploration  showed  a  high  cancer  of  rectum  with  adhesion  to 
bladder,  and  multiple  metastases  scattered  over  pelvic  peritoneum.  The 

P-d  splenic  flexure  was  sutured  to  abdominal  wall  in  such  a  manner  as  to 

maUe  cocaine  enterostomy  easy  later.    Comp. — None. 
Result:  The  patient   returned   to  his   work,  but   the  enterostomy  was 
necessitated  several  months  later  and  since  then  two  secondary  opera- 
tions have  been  done;  but  in  Nov.,  1913,  the  patient  was  rapidly  failing. 
Died  in  Dec,  1913. 

69.  Oct.  28,  1912.  Male— 54.  Under  the  care  of  Dr.  Harvey  Gushing. 
_  Major  trigeminal  neuralgia.  Op.  (H.  G.) — Sensory  root  avulsion. 
^  ^            Comp. — None. 

Result:  Mar.  16,  1916— Dr.  C.  reports,  "Well." 

70.  Nov.  1,  1912.  Male — 5i.  Under  the  care  of  Dr.  Harvey  Gushing. 
O  K             Cerebral  birth  palsy.    No  op. 

Result:  No  report. 

20 


E-s 
P-d 


71.  Nov.   1,    1912.     Male — 64.     Under   the   care   of   Dr.   Harvey   Gushing. 
Major    trigeminal    neuralgia.    Op.     (H.    C.) — Sensory    root    avulsion.    r\  rr 
Comp. — None. 

Result:  July  31,  1916— Dr.  C.  reports,  "Well." 

72.  Nov.  6,  1912.    Male.    Right  inguinal  hernia.    Op.  (E.  A.  C.  and  G.  W. 

M.) — Ferguson  method.    Comp. — None.  q  t^ 

Result:  Aug.,  191.3 — Well  (phvsician).  Nov.  4,  1916 — Friend  reports 
him  "Well.'' 

73.  Dec.   4,   1912.     Female.     Turkey  bone  impacted  in  oesophagus.     Bone 
pushed  into  stomach  by  bougie.    Comp. — None.  O  K 
Result:  Sept.,  1913 — No  further  trouble  from  this  cause. 

74.  Dec.  4,  1912.  Female — 30.  For  many  years  had  suffered  from  con- 
stipation, lassitude,  toxic  headaches,  undue  fatigue,  dysmenorrhosa, 
abdominal  discomfort  and  soreness.  The  appendix  had  been  removed  a 
year  previously  by  E.  A.  C.  Pre-op.  diag. — Intestinal  stasis.  Operation 
was  undertaken  with  the  intention  of  doing  iliosigmoidostomy.  Op. 
(E.  A.  C.) — Double  hydrosalpinx  with  enormous  flaccid  dilatation  of 
both  tubes  was  found.  Double  salpingectomy  and  peritoneal  plastic. 
Comp. — Slight  serous  discharge  from  wound  causing  no  delay  in  con- 
valescence. 

Result:  Aug.  24,  1913 — Greatly  improved,  but  still  has  toxic  headaches. 
Jan.,  1914 — Well,  except  slight  headaches.  July  18,  191-5 — "I  am  enjoy- 
ing better  health  than  ever  before.  Once  in  a  while  sick  times  with  my 
stomach."  Aug.  9,  1916- — Letter — Not  as  well  as  last  year.  Abdominsd 
soreness,  but  no  pain.    Other  minor  symptoms. 

75.  Dec.  5,   1912.    Male.    Injury  to   elbow.    X-ray.    No   fracture.    Prompt    q  g 
recovery.    No  report. 

76.  Dec.  7,  1912.  Male — 43.  SjTnptoms  of  duodenal  ulcer  for  many  years. 
Persistent  vomiting,loss  of  compensation  in  muscular  power  of  stomach, 
arterio-sclerosis,  marked  albuminuria.  Bid.  pressure  240.  This  patient 
was  kept  under  lavage  for  9  days  to  restore  the  compensation  of  the 
stomach.  The  operation  was  then  done  without  post-operative  pain  or 
shock  under  the  principles  of  anoci-association.  Op.  (E.  A.  C.) — Moy- 
nihan  operation  of  gastro-enterostomy  and  infolding  of  duodenal  ulcer. 
Comp. — None. 

Result:  The  patient  had  no  return  of  stomach  symptoms  during  his 
life.  He  returned  to  hard  work  as  a  lawyer  and  seemed  in  better  health 
than  for  years  until  May,  when  he  was  taken  with  acute  cardio-renal 
symptoms  and  died  on  May  14,  1913. 

77.  Dec.  9,  1912.  Female — 59.  Recent  attacks  of  gallstone  colic.  Op,  (E. 
A.  C.) — Cholecystostomy  for  cholelithiasis.  Ap.  adherent.  Appendec- 
tomv.    Comp. — None. 

Result:  Sept.,  1918— Well.  July  17,  1915— Well.  Not  exam.  Aug.  1, 
1916 — Letter — "During  the  last  year  or  so  I  have  had  several  attacks 
of  pain  exactly  like  the  old  ones  and  typical  of  gallstones,  but  not  quite 
so  severe,  though  on  one  occasion  I  packed  a  suit  case,  expecting  to 
sojourn  with  you  again."  E-j 

(P.S.    After  completion  of  analysis.) 

April  17,  1917.  Re-entry  for  persistent  biliary  colic  recurring  at  sliort 
intervals.  General  malaise.  Op.  (E.  A.  C.  and  G.  F.  L.,  Jr.) — Exten- 
sive adhesions  found  in  whole  right  upper  quadrant.  A  small  gall 
bladder  contracted  on  a  single  gallstone  was  removed  with  great  diffi- 
culty. (Tiie  five  gallstones  removed  at  the  previous  operation  had  been 
black  and  friable,  but  this  one  was  lemon-yellow,  hard  and  crystalline. 
The  mucosa  was  studded  with  crystalline  deposits  and  had  the  "straw- 
berry" appearance.)    The  dissection  was  extremely  difficult  on  account 

21 


P-d 


E-s 


E-j 
E-s 


of  the  old  adhesions,  fat,  and  high  position  of  the  gall  bladder.  The 
common  duct  was  very  small  and  thin-walled,  so  that  I  felt  sure  it 
contained  no  stones.  The  gall  bladder  was  freed  and  the  cystic  duct 
tied  off.  At  this  point  there  was  a  sharp  hemorrhage  from  the  cystic 
artery,  which  was  soon  checked  with  a  clamp,  and  a  tie  placed.  The 
tie  on  the  cystic  duct  was  left  long,  as  is  my  custom  in  cholecystectomy, 
so  that,  should  a  stone  in  the  common  duct  be  overlooked  and  jaundice 
develop,  the  tie  could  be  pulled  off.  The  wound  was  closed  with  cigar- 
ette drains. 

Following  the  operation  there  seemed  to  be  an  undue  amount  of 
post-operative  pain.  On  the  second  day  slight  jaundice  began  to  de- 
velop, but  at  the  same  time  a  profuse  discharge  of  bile  came  through 
the  wound  and  the  intense  pain  abated  somewhat.  On  the  third  and 
fourth  days  the  jaundice  deepened,  and  yet  the  bile  drained  even  more 
profusely.  On  the  fourth  day  the  temperature  and  respiration  rose, 
and  signs  of  consolidation  in  the  right  base  appeared  soon  after.  The 
tie  was  pulled  off  the  cystic  duct  under  the  supposition  that  the  jaundice 
might  be  due  to  a  stone  in  the  common  duct  which  had  escaped  our 
notice.  The  biliary  drainage  through  the  wound  I  supposed  due  to  the 
oozing  of  the  raw  surface  of  the  liver  in  which  the  gall  bladder  had  been 
embedded. 

The  patient  died  on  the  seventh  day.  During  all  this  anxious  period 
the  condition  of  the  abdomen  and  of  the  wound  itself  remained  so  good 
that  I  was  sure  that  no  peritonitis  existed.  There  was  evidently  some 
consolidation  in  the  right  base,  but  the  patient's  condition  seemed  worse 
than  could  be  accounted  for  by  this  alone.  I  was  so  sure  that  I  had 
done  the  operation  correctly,  that  I  never  once  suspected  the  true  cause 
of  the  unusual  condition — division  and  ligation  of  the  hepatic  duct.  A 
post-mortem  examination  through  the  incision  showed  that  the  cut  ends 
of  the  hepatic  duct  lay  free  in  the  wound.  There  was  no  sepsis  and 
the  tissues  looked  exactly  as  thej'^  had  done  when  I  closed  the  wound 
after  operation,  except  that  the  tie  had  been  pulled  off  the  cystic  duct 
and  there  was  no  tie  on  the  proximal  end  of  the  hepatic  duct — where 
I  remembered  having  placed  one  at  the  time  of  the  hemorrhage,  and 
had  supposed  the  duct  was  a  vein. 

In  other  words,  I  had  made  an  error  of  skill  of  the  most  gross 
character,  and  even  then  failed  to  recognize  that  I  had  made  it.  More 
than  that,  I  would  not  have  believed  it,  unless  I  had  made  the  post- 
mortem examination  myself  and  seen  it  with  my  own  eyes.  It  was  then 
clear  why  the  intense  pain  came  in  the  first  24  hours  (total  biliary 
obstruction  from  ligation  of  the  hepatic  duct)  ;  why  it  abated  when  the 
biliary  discharge  came  (hyperdistention  of  the  duct  pushed  off  the  tie)  ; 
why  the  jaundice  came  even  when  the  wound  was  discharging  bile 
(absorption  of  bile  in  the  blood  for  the  first  2-1  hours),  and  why  the 
abdominal  condition  was  good   (the  wound  was  clean). 

I  think  the  patient  died  from  pneumonia,  but  she  could  not  have 
lived  with  a  divided  hepatic  duct,  and  she  might  have  survived  the 
pneumonia  if  not  handicapped  by  the  tem])orary  biliary  obstruction. 

To  such  errors  experience  owes  its  value.  Some  of  the  knowledge 
thus  gained  cannot  be  transmitted,  but  it  needs  only  this  case  to  teach 
me  that  if  a  case  of  cholecystectomy  shows  excessive  pain  in  the  first 
2\  hours  which  abates  on  the  second  day  at  the  time  of  slight  jaundice 
and  an  excess  of  biliary  discharge,  probably  the  hepatic  duct  has  been 
cut  and  ligated,  even  if  the  surgeon  who  operated  is  sure  that  it  was 
not. 

78.  Dec.  16,  1912.  Female — 54.  Had  been  operated  on  by  E.  A.  C.  three 
years  previously  for  cancer  of  the  breast.  For  more  than  a  year  before 
entrance  she  had  showed  symptoms  of  a  metastasis  in  the  dorsal  spine. 
There  was  intense  girdle  pain,  excessive  nausea  and  incessant  vomiting. 

22 


For  three  weeks  no  nourishment  had  been  retained  and  even  a  grain  of 
morphine  in  24°  failed  to  keep  her  comfortable.  She  was  taken  into  the 
hospital  for  diagnosis  and  an  X-ray  exam,  of  the  spine.  The  latter 
showed  a  well-marked  defect  in  the  body  of  a  dorsal  vertebra.  Abdom- 
inal operation  was  considered  because  for  years  she  had  had  symptoms 
of  gallstones  and  it  was  felt  that  possibly  the  latter  might  be  causing 
the  present  symptoms.  Operation  was  decided  against  by  E.  A.  C.  on 
the  ground  that  the  patient's  condition  was  too  poor  and  offered  very 
little  hope.  Emaciated,  almost  pulseless,  she  was  taken  home  to  die. 
Result:  After  her  return  home  this  patient  was  treated  by  her  husband 
(a  physician)  and  another  physician  and  by  a  Christian  Scientist.  For 
several  weeks  she  lay  between  life  and  death  but  eventually  recovered. 
On  Aug.  26,  1913,  her  husband  wrote  as  follows:  "My  dear  doctor: 

I  am  glad  to  report  that  Mrs.  is  gaining  every  day.     She  has 

gained  six  pounds  since  the  first  day  of  July.    She  is  better  than  she 
ever  has  been.    She  is  able  to  eat  things  she  has  never  been  able  to  eat 
before  since  she  was  twenty  years  old,  and  digest  them  perfectly  with- 
out any  trouble.    Has  no  gases  and  is  free  from  pain  of  any  kind  in    tj.  jj 
her  spine.    I  feel  satisfied  that  her  trouble  was  gallstones,  and  I  believe       " 
she  expelled  a  large  one  on  the  25th  or  26th  of  December,  as  on  that  day    p  , 
we  had  a  great  deal  of  trouble  during  a  movement.     And  after  that 
time  I  examined  and  weighed  everything  that  entered  her  stomach  or 
left  her,  but  she  certainly  is  better  than  she  has  been  for  years." 

This  was  certainly  a  recovery  "when  the  doctors  had  given  her  up." 
It  was  as  miraculous  as  any  surgical  "cure"  that  I  have  ever  seen. 
Should  it  be  placed  to  the  credit  of  Christian  Science  or  added  to  the 
lists  of  the  Follies  of  Wisdom,  at  least  it  will  always  leave  me  with 
some  hope  for  hopeless  cases.  (E.  A.  C.)  On  May  2,  1914,  reported 
well.  July  29,  1915 — Husband  reports  symptoms  suggestive  of  recur- 
rence in  lungs ;  dyspnoea,  loss  of  weight,  and  abdominal  attacks  requir- 
ing morphia.  Aug.  21,  1916 — Husband  reports  that  on  Dec.  3,  1915,  an 
exploratory  laparotomy  for  pelvic  symptoms  was  done  by  another 
surgeon.  Metastases  in  the  liver,  and  other  abdominal  metastases  were 
found.  At  present,  patient  is  in  fair  condition  and  still  enjoys  life. 
Mar.  23,  1917 — Seen  at  patient's  home.  Is  able  to  sit  up  and  obtains 
much  comfort  from  Christian  Science.  Somewhat  emaciated.  Abdomen 
greatly  enlarged.    Evident  metastases  in  cervical  glands. 

79.  Dec.  20,  1912.    Female— 68.    Carcinoma  of  the  right  side  of  the  tongue.    O  K 
Op.   (E.  A.  C.  and  G.  W.  M.)— Removal  of  right  half  of  the  tongue 

and  dissection  of  the  right  side  of  the  neck.    Drainage.    Path,  report — 

Cancer.    Comp. — None. 

Result:  Feb.  25,  1917 — Died  of  apoplexy.    Had  had  no  recurrence  of 

cancer. 

80.  Dec.  22,  1912.  Male — 71.  Hematuria  from  hjq^ertrophied  prostate.  Op. 
(E.  A.  C.  and  G.  W.  M.  Spinal  anaesthesia  by  Dr.  Freeman  Allen) 
— Suprapubic  prostatectomy.  Comp. — Double  epididymitis.  Re-entry 
May  19,  1913.  Transient  attack  of  epididymitis  which  quieted  down 
with  rest. 

Result:   Aug.   23,   1913— Well.     Bacteriuria.     Mar.  30,  1915— Died  of 
angina  pectoris  and  grippe. 


E-s 


81.  Dec.  30,  1912.    See  note  on  case  125. 

Result:  July  31,  1916— Dr.  B.  reports,  "Well." 


O  K 


82.  Dec.   30,   1912.    Female— 30.    Dysmenorrhoea.    Op.    (G.   W.   M.)— Dila- 
tation and  curettage.  O  K 
Result:  Sept.,  1913— Well. 

23 


83.  Jan.  10,  1913.  Male — 8.  Congenital  right  inguinal  hernia.  Op.  (G.  W. 
M.) — Radical  cure  of  right  inguinal  hernia.    Comp. — None. 

O  K  Result:    Aug.,    1913— Well.     Re-entry,   Mar.    14,    1913— Left   inguinal 

hernia.    Op.  (G.  W.  M.) — Radical  cure.    Comp. — None. 
Result:  Aug.  8,  1916— Dr.  M.  reports,  "Perfectly  well  May,  1916." 

84.  Jan.   11,   1913.    Female — 23.    Epigastric  pain   and    distress.    Vomiting. 
p  Diag. — Duodenal  ulcer.    Operation  advised  and  refused,  diet  prescribed. 

Result:  Sept.,  1913 — Stomach  still  "weak,"  but  able  to  work  as  house- 
maid.   Occasional  vomiting. 

85.  Jan.  22,  1913.  Female — 57.  Cancer  of  cervix  uteri.  Con't — Dr.  Farrar 
Cobb,  who  advised  ligation  of  internal  iliac  arteries,  as  growth  was  too 
extensive  for  radical  operation.    Operation  refused. 

P-d  Result:  Patient  has  had  X-ray  treatment  through  the  abdominal  wall 

by  a  "specialist"  in  the  regular  profession.  Aug.,  1913 — No  appreciable 
change  in  condition.  May,  1914 — Death  has  been  reported  without  exact 
date. 

86.  Jan.  23,  1913.  Female — 36.  For  several  years  had  had  a  chronic  cough 
with  a  small  amount  of  sputum  which  was  occasionally  blood-tinged. 
Repeated  examinations  by  specialists  had  failed  to  reveal  physical  signs 
in  the  nose,  throat  or  chest,  or  of  tubercle  bacilli  in  the  sputum.  On 
Jan.  23,   1913,   she  was  suddenly  taken  with  an   epileptiform  seizure. 

E-d  She  was  seen  in  consultation  by  Dr.  E.  W.  Taylor  and  by  Dr.  Harvey 

Gushing,  and  on  Feb.  15,  1913,  was  removed  to  the  Brigham  Hospital 

P-d  to  be  under  Dr.  Cushing's  care.    After  thorough  examination  she  was 

subjected  to  a  decompressive  craniotomy  under  the  pre-operative  diag- 
nosis of  brain  tumor.  Great  intracerebral  pressure  was  found,  but  even 
after  the  operation  no  localizing  signs  developed. 

Result:  She  died  soon  after.  Autopsy  showed  a  huge  brain  abscess  and 
a  chronic  bronchiectasis  to  which  it  was  probably  due. 

87.  Jan.  23,  1913.  Female.  Tumor  in  the  lower  abdomen  extending  into 
post  cul-de-sac.  Previously  had  had  three  operations  by  other  surgeons 
for  salpingitis.    Pre-op.  diag. — Cyst  of  broad  ligament.    Op.  (E.  A.  C. 

_  _,  and  G.  W.  M.) — Excision  of  multiple  cystic  tumors  probably  arising 

^  ^  from    right   ovary.     A   gallstone    removed   and    gall   bladder    sutured. 

Careful  peritoneal  plastic,  covering  raw  surfaces;  left  ovary,  though 

adherent,  not  removed.    Comp. — None. 

Result:  Aug.  1,  1915 — Physician  states  that  she  is  well.    Aug.  7,  1916 — 

Husband  telephones  that  she  is  well. 

88.  Jan.  25,  1913.    Female— 26.    Breast  abscess.    Op.  (G.  W.  M.)— Opened 
O  K  and  drained.    Comp. — None. 

Result:  Aug.,  1913— Well. 

89.  Jan.  27,  1913.  Male.  Acute  appendicitis.  Under  the  care  of  Dr.  F.  B. 
Harrington.    Op.   (F.  B.  H.) — Appendectomy  and  drainage.    Comp. — 

_  __  None. 

^  ^  Result:  Well  in  spring  of  1913.     (F.  B.  H.)     July  19,  1915— Exam. 

Scar  solid.  No  abdominal  symptoms.  Has  since  been  operated  on  by 
another  surgeon  for  tonsils  and  adenoids.  Acne.  July  31,  1916 — Well. 
Acne  "since  he  had  appendicitis." 

90.  Jan.  27,  1913.  Stout  female— 36.  Abdom.  pain  of  12  hours'  duration. 
Pre-op.  diag. — Subacute  appendicitis.  Op.  (E.  A.  C.  and  G.  W.  M.)  — 
Appendectomy.    Appendix  showed  evidence  of  a  previous  attack  but 

E"*'  no  sign  of  acute  inflammation.    Comp. — None. 

Result:  Aug.,  1913— Well.  Aug.  18,  1915— Now  has  symptoms  of  gall- 
stones.   Op.  advised.    Scar  solid. 

24 


91.  Feb.  1,  1913.  Female— 22.  Ugly  scar  on  upper  lip.  Op.  (E.  A.  C)  — 
Completion  of  a  plastic  operation  previously  done  by  E.  A.  C.  Comp. 
— None. 

Result:  Nov.,  1913— Appearance  greatly  improved.   June,  1915— Much 
improved,  but  still  discontented  vi'ith  scar. 

92.  Feb.  4,  1913.    An  elderly  man  with  uncompensated  organic  heart  lesion.    p_^ 
Under  the  care  of  his  private  physician. 

Result:  Died  Mar.  2,  1913. 

93.  Feb.  5,  1913.  S.  female— 25.  Acute  abdominal  pain  of  6  hours'  dura- 
tion.   Pre-op.  diag. — Acute  appendicitis.    Con't— Dr.  F.  B.  Harrington. 

Op.   (E.  A.  C.  and  G.  W.  M.) — Appendectomy.    Appendix  acutely  in-    O  K 
flamed  but  not  perforated.    Closed  without  drainage.    Comp. — None. 
Result:  Aug.  2,  1916— Well. 

94.  Feb.  13,  1913.  A  poorly  developed  female — 28.  Constipation,  vague 
abdominal  pain,  backache,  frequency  of  micturition,  visceral  ptosis  and 
all  the  signs  of  intestinal  intoxication.  Expl.  op.  (E.  A.  C.  and  G.  W. 
M.) — A  strictured  appendix  removed.  Marked  ptosis.  Colopexy  by 
method  of  CoiTey.  Ventral  suspension  of  uterus.  Comp. — None. 
Result:  Aug.  26,  1913 — Great  improvement  in  general  symptoms  for 
months,  but  recently  partial  relapse.  On  the  whole,  a  satisfactory  gain  p.^ 
and  at  present  gaining  (letter).  Apr.  28,  1914— Condition  decidedly 
better  than  before  op.  July  24,  1915 — Some  slight  improvement  from 
operation,  but  not  well.  Has  been  treated  at  Clifton  Springs  Sani- 
tarium during  the  last  winter.  Aug.  1,  1916 — Letter — Decidedly  im- 
proved, having  gained  25  pounds  in  weight  and  considerable  strength. 
Still  unable  to  stand  a  normal  amount  of  fatigue. 

96.  Feb.    20,    1913.     Female — 38.     Dysmenorrhoea   and    endometritis.     Op. 

(G.  W.  M.  and  E.  A.  C.)— Dilatation  and  curettage  and  ventral  sus-    q  ^ 
pension.    Comp. — None. 
Result:  Aug.,  1913— Well. 

96.  Mar.  5,  1913.    Male— 37.    Tumor  of  left  parotid.    Pre-op.  diag.— En- 
chondroma.  Op.  (E.  A.  C.  and  G.  W.  M.) — Cocaine.  Excision  of  tumor 
which  involved  facial  nerve  and  proved  to  be  adeno-carcinoma.    Comp. 
—Facial  paralysis.    Re-entry.— Op.  (E.  A.  C.  and  G.  W.  M.)— Radical    jj.^ 
removal  of  entire  parotid  and  dissection  of  neck. 

Result:  Aug.,   1913 — An  enlarged  gland  beneath  sterno-mastoid.    Op.    p.^ 
advised  and  refused.    (A  tumor  size  of  pea  had  been  removed  from  this 
patient's  eyelid   (left)   several  years  before.)     Physician  reports  that 
patient  died  on  Dec.  24,  1914,  of  diabetic  coma  and  acute  lung  infec- 
tion. 

97.  Mar.  7,  1913.    See  case  125.  O  K 
Result:  Sept.  2T,  1915— Dr.  B.  reports,  "Well." 

98.  Mar.  8,  1913.    Male — 50.    Dislocated  shoulder;  one  week  duration.    Op. 

(E.  A.  C.  and  G.  W.  M.)— Ether  reduction.  O  K 

Result:  Aug.,  1913— Well. 

99.  Female — 30.  Acute  abdom.  pain.  Pre-op.  diag. — Ovarian  cyst  with 
twisted  pedicle.    Op.  refused. 

Result:  Patient  writes  on  Sept.  15,  1913,  that  she  has  been  quite  well    ^-^ 
and  has  gained  weight.    She  has  occasional  pain  in  her  side  and  expects 
to  be  operated  upon  later. 

100.  Mar.  13,  1913.    See  case  125.  O  K 
Result:  July  31,  1916— Dr.  B.  reports,  "Well." 

101.  Mar.  14,  1913.    Male — 40.    Double  inguinal  hernia.    Op.   (G.  W.  M.)— 
Double  Bassini.    No  sac  on  left  side.    Comp. — None.  O  K 
Result:  Aug.  17,  1915— WeU.    (Dr.  M.) 

25 


102.  Mar.  15,  1913.  Female.  Attacks  of  right-sided  abdominal  pain  and 
general  debility.  Pre-op.  diag. — Chronic  salpingitis.  Op.  (E.  A.  C.  and 
G.    W.    M.) — Double   salpingectomy    and    oophorectomy    for    adherent 

O  K  tubes,  chronic  ovarian  inflammation.    Peritoneal  plastic.    Comp. — None. 

Result:  Aug.  2i,  1915 — Since  op.  has  had  menorrhagia,  but  it  is  not 
severe  now.  Looks  well.  Has  "indigestion."  Exam.  Scar  solid.  Uterus 
free]}"-  movable;  not  tender.  Aug.  1,  1916 — Letter — "Much  better  and 
stronger  than  last  year." 

103.  Mar.  17,  1913.  Male — 29.  Very  large  right  inguinal  omental  hernia. 
Op.  (E.  A.  C.  and  G.  W.  M.) — Excision  of  about  2  lbs.  of  omentum  and 
Bassini  operation.    Comp. — None. 

Result:  Nov.  17,  1913— Well;  slight  hydrocele.  July  20,  1915— Condi- 
tion same — small  hydrocele  without  tension.    Nov.  27,  1916 — Re-entered 

■n>  for  radical  cure  of  hydrocele  which  has  grown  much  larger.    Op.   (E. 

A.   C) — Very  thick  sac,  rough  on  inside  with  tubercular  projections. 

p  Impossible  to  distinguish  epididymis.    Portion  of  sac  excised.    Patho- 

logic report,  "Some  tubular  elements  resemble  those  of  the  epididy- 
mis." Comp. — Hematoma  developed.  Scrotum  incised  to  drain  it.  In 
doing  this,  testicle  was  cut  for  about  i  inch.  This  was  sewed  up. 
Hematoma  subsided  slowly.  Removal  of  testicle  advised,  but  refused 
by  patient.  Discharged  Dec.  22,  1916,  against  advice,  with  scrotum  stiU 
swollen  and  with  small  granulating  point  on  lower  wound.  Feb.  15, 
1917 — Letter  stating  that  the  testicle  had  been  removed  by  another 
surgeon,  and  was  found  to  be  injured  in  three  places. 

104.  Mar.  18,  1913.    S.  female— 52.    Hemorrhoids.    Op.  (E.  A.  C.  and  G.  W. 
■c'  i              M.) — Clamp  and  cautery.    Comp. — None. 

■•'  Result:  Dec.   9,  1913 — Well,  except  for  discomfort  from  "tabs"   and 

slight  itching. 

105.  Mar.  21,  1913.  Male — 42.  Acute  intestinal  obstruction  of  34  hours' 
duration.  Repeated  attacks  of  abdominal  pain  for  one  month.  Right 
iliac  abdom.  tumor.  Pre-op.  diag. — Acute  appendix  abscess.  Op.  (E. 
A.  C.  and  G.  W.  M.) — Excision  of  an  intussusception  of  small  bowel 
in  which  the  advancing  point  was  a  Meckel's  diverticulum.  Lateral 
anastomosis  and  temporary  proximal  enterostomy  which  was  closed  on 

j^.jj  the  fourth  day  without  ether.    Comp. — None. 

Result:  Sept.  8,  1913 — Re-entry  for  removal  of  proximal  end  of  bowel 
which  practically  made  a  hernia  in  scar.  Op.  (E.  A.  C.  and  G.  W.  M.) 
— Old  scar  excised  and  redundant  portion  of  bowel  removed.  Careful 
peritoneal  plastic.    Comp. — None. 

Result:  May  2,  1914 — Well  (exam.).  No  hernia.  Slight  pain  in  scar. 
Aug.  17,  1916 — Physician  reports,  "Patient  has  some  trouble  with 
bowels,  but  as  well  as  before  intestinal  obstruction  occurred." 

106.  Mar.  23,  1913.  S.  female — 32.  Large  abdominal  tumor.  Pre-op.  diag. 
— Large  fibroid   or  cyst  of  ovary.     Op.    (E.   A.  C.   and  G.  W.  M.) — 

Q  T^  Hvsterectomv  for  fibroid  tumor.    Comp. — None. 

Result:  Aug',  191.3— Well.  July  22,  1915— Scar  O.  K.  but  rather  weak. 
Ever  since  operation  has  noticed  hot  flashing.  Aug.  8,  1916 — Well, 
though  still  has  hot  flashes. 

107.  Mar.  24,  1913.    Male — 40.    Recurrent  attacks  right-sided  epididymitis. 
O  K             ^r>'  ^^'  ^^  ■  ^^"^ — Epididymectomy.    Comp. — None. 

Result:  Aug.  8,  1916 — Dr.  M.  reports,  "Still  has  thickening  in  cord  on 
left." 

108.  Mar.   26,   1913.    Female — 24.    Varicose  veins  of  right  leg.    Under  the 
P-d              care  of  Dr.  Hermann  Bucholz.     Op.  (H.  B.) — Partial  excision  of  veins. 

Comp. — None. 
E-s  Result:  July  25,  191.5 — Still  suffers  a  good  deal  from  pain  in  the  leg 

and  arch  of  foot.    (Letter  to  Dr.  B.) 

26 


OK 


109.  Mar.  26,  1913.  Male — 25.  Chronic  inflammatory  epiclidymitis.  Double. 
Op.  (G.  W.  M.) — Partial  double  epididj^mectomy.    Comp. — None. 

Result:  Aug.,  1913— Well.    Re-entry,  Sept.  20,  1913— Remains  of  right    E-j 
epididymis  removed.  Drainage.  Sinus  to  stump  of  left  wound  removed. 
Comp. — None.  E-d 

Result:  Nov.  1,  1913— Well.  June,  1915— Dr.  M.  reports:  "Although 
patient  has  no  symptoms,  there  is  still  thickening  in  stump  of  vas,  and 
twice  since  operation  a  small  sinus  has  broken  open  (Tuber.?),  although 
path,  report  was  chronic  inflamm." 

110.  Mar.  27,  1913.  Male — 57.  Tumor  in  right  iliac  fossa.  Cachexia;  loss 
of  weight  and  abdominal  pain.  Pre-op.  diag. — Cancer  of  cecum.  Op. 
(E.  A.  C.  and  G.  W.  M.) — Excision  of  cecum,  ascending  colon  and  a 
portion  of  ileum  and  another  coil  of  small  intestine  together  with  a  por- 
tion of  the  abdominal  wall  en  masse.  Four  end  closures  and  two  lateral 
anastomoses  of  the  intestine.  Plastic  of  abdominal  wall  to  cover  defect. 
This  operation  was  done  under  the  principles  of  anoci-association.  It 
was  started  with  a  pulse  of  72,  took  3^  hours  and  finished  with  a  pulse 
of  80.  There  was  no  obvious  shock  and  almost  no  post-operative  pain. 
Comp. — Serous  discharge  along  the  course  of  wick — probably  ascitic 
peritoneal  leakage. 

Result:  Apr.  17,  1917 — Exam. — "Well.  Scar  rather  weak.  No  evidence 
of  recurrence. 

111.  Mar,  27,    1913.    Male — 68.    Cj^stitis  and  gout  which   were  temporarily 
relieved  by  rest  in  bed.    Prostatectomy  advised  and  refused.  p_j. 
Result:  July  20,  1915 — Writes  that  he  is  still  alive  but  gives  no  details. 
June  25,  1916 — Son  reports  that  he  is  about  the  same. 

112.  Apr.  4,  1913.  Stout  female — 47.  Stiff,  partially  flexed  knee  and  symp- 
toms of  dislocation  of  semilunar  cartilage  of  many  years'  duration.  No 
relief  from  a  recent  ether  manipulation  by  another  surgeon.  Op.  (E.  A. 
C.  and  G.  W.  M.) — A  damaged  semilunar  cartilage  removed  in  halves 
by  ant.  and  post,  incisions.  Comp. — None  except  induration  in  popliteal 
space,  probably  from  escaping  fluid.  E-j 
Result:  Aug.  14,  1913 — Patient  still  limps  badly  and  motion  of  knee  is 

a  little  less  than  90  degrees,  but  still  improving.  Apr.,  1914 — Much 
improved.  July  21,  1915 — Walks  without  limp,  unless  tired.  Leg 
serviceable  but  still  cannot  bend  knee  beyond  right  angle.  Has  to  sidle 
downstairs.  Dec.  30,  1916 — Exam. — Walks  without  limp,  but  flexion 
only  to  right  angle. 

113.  Apr.   6,    1913.    Male — 12.    Acute   right-sided   abdominal  pain.    Diag. — 
Acute  appendicitis.    Op.   (G.  W.  M.) — Appendectomy.    Appendix  gan-    Q  jj; 
grenous.    Comp. — None. 

Result:  Aug.  8,  1916— Dr.  M.  reports,  "Well." 

114.  Apr.  13,  1913.  S.  female — 46.  Irregular  fibrous  enlargement  of  both 
breasts.  Pre-op.  diag. — Chronic  mastitis.  Con't — Dr.  R.  B.  Greenough. 
Op.  (E.  A.  C.  and  G.  W.  M.) — Amputation  of  both  breasts.  Comp. — 
None.    Path.  exam,  showed  fibrosis  with  nearly  complete  disappearance 

of  glandular  tissue.    In  one  breast  was  an  area  of  cancer  so  small  that    ^'^ 
the  whole  tumor  was  visible  in  low  power  field  of  microscope.    Comp. — 
A  slight  necrosis  of  edge  of  skin  size  half  dime. 

Result:  Aug.,  1913 — Well,  except  for  a  small  uncomfortable  tab  on  scar. 
This  was  removed  under  cocaine.    Aug.  19,  1916 — Letter — Well. 

116.  Apr.  22,  1913.     S.  female — 30.     Clear  history  of  repeated  attacks   of 
appendiceal  colic.    Op.  (E.  A.  C.  and  G.  W.  M.) — Appendectomy  under 
local  anaesthesia  with  a  few  breaths  of  nitrous  oxide.    A])pendix  stric-    q  t^ 
tured;  filled  with  concretions.    Scarcely  any  operative  or  post-operative 
pain.    Comp. — None. 

Result:  Aug.  2,  1916 — "I  have  never  felt  more  absolutely  weU." 

27 


116.  Apr.  23,  1913.  Nervous  female — 24.  Persistent  pain  in  right  iliac 
region  worse  at  ctm.  Pre-op.  diag. — Cecum  mobile.  Op.  (E.  A.  C.  and 
G.  W.  M.) — Appendix  was  found  plastered  on  cecum  by  a  "Jackson's 
veil."     Partial   rotation  of  cecum  so  that  ileum  entered  from  behind; 

P-d  ai)pendectomy ;  appendix  normal.    Comp. — None. 

Result:  Greatly  improved  by  operation,  but  still  has  vague  pain  on 
right  of  al)domen.  July  27,  1915 — Scar  O.  K.  Many  vague  complaints, 
including  dysmenorrhoea,  dyspareunia,  leucorrhoea,  and  sterility.  Looks 
perfectly  well.  Feb.  12,  1917 — Exam. — Much  depressed.  No  benefit 
from  operation.    Nevertheless,  physical  examination  is  negative. 

117.  Apr.  24,  1913.  Female — 26.  Persistent  abdominal  discomfort,  nausea, 
constipation,  weaitness  and  nervousness.  Came  for  diagnosis  and  X-ray 
examination.    A  diagnosis  of  general   ptosis  was  made  and  operation 

P-d  was  not  advised.    Careful  instruction  in  hygiene  was  given. 

Result:  Aug.  29,  1913 — Considerable  improvement  but  same  symptoms 
persist  (letter).  Aug.  6,  1915 — Has  improved  steadily,  but  this  summer 
has  had  several  attaclis  of  "colitis."  Nov.  10,  1916— Letter— Well, 
except  for  some  attacks  of  colitis  last  winter. 

118.  Apr.  30,  1913.  Male — 38.  Dislocation  of  wrist  and  fracture  of  carpal 
scaphoid  of  several  weeks'  duration.  Under  ether  without  incision  the 
dislocation  was  reduced  and  the  scaphoid  fragment  replaced  by  E.  A. 
C.'s  method.    Comp. —  None. 

p_r  Result:  Aug.,  1913 — Fair  motion.    Improving.    Aug.  8,  1916 — Exam. — 

Good  serviceable  wrist,  but  some  tenderness  and  pain  on  forced  flexion 
and  extension.  Nov.  29,  1916 — Strained  wrist  a  week  ago.  States  that 
wrist  bothers  him  a  little  all  the  time.  Advised  to  have  scaphoid  frag- 
ment removed.    Refused. 

119.  May  2,  1913.  S.  female — 43.  E.  A.  C.  had  operated  for  cancer  of  the 
breast  3  years  before.  Palpable  supraclavicular  gland.  Op.  (E.  A.  C. 
and  G.  W.  M.) — Glands  removed  from  supraclavicular  space  proved  to 

g_j  be  normal.    Comp. — None. 

Result:  Aug.,  1913— Well.  May,  1914— Has  since  been  op.  for  glands 
in  opposite  axilla.  Died  at  Huntington  Hospital  (No.  CI — 15 — 20)  on 
Mar.  6,  1915,  of  metastases  in  lungs. 

120.  May  9,  1913.  Male— 25.  Traumatic  amputation  of  finger.  Op.  (G.  W. 
M.) — Reamputation.    Comp. — None. 

O  K  Result:  Aug.,  1913— Well.    Aug.  8,  1916— Dr.  M.  reports,  "Small  piece 

of  new  finger  nail  removed  in  July,  1916." 

121.  May  12,  1913.  S.  female— 24.  Recurrent  attacks  of  pain  in  right  iliac 
fossa,  dysmenorrhoea  and  prolapse  of  the  right  ovary.  Pre-op.  diag. — 
Chronic  appendicitis.  Op.  (E.  A.  C.  and  G.  W.  M.)— Removal  of  a 
strictured  appendix  and  suspension  of  right  ovary.  Comp. — None. 
Result:  Apr.,  1914— Well.  July  30,  1915— At  present  somewhat  run 
down,  but  symptoms  for  which  operation  was  undertaken  were  com- 
pletely   relieved.    Scar    solid.    Aug.    12,    1916— Exam.— Married    since 

O  K  operation.  Lacerated  from  instrumental  delivery  from  which  she  is  still 

convalescent.  No  furtiier  symptoms  similar  to  those  previous  to  opera- 
tion. Perineorrhapy  advised.  Re-entered  Dec.  29,  1916.  Op.  (E.  A.  C. 
and  W.  P.  C.)— Extremely  bad  lacerations  of  the  cervix,  lateral  walls 
of  the  vagina  and  anal  sphincter  were  repaired  by  plastic  operation. 
Levator  ani  on  left  side  had  been  practically  destroyed,  and  vaginal 
scar  had  healed  to  inner  side  of  pubes.  Comp.— Slight  post-operative 
hemorrhage  and  grii)pe.    June  20,  1917— Husband  reports,  "Well." 

122.  May  15,  1913.  M.  female — 42.  Diagnosis— Gallstones.  Lost  her  courage 
P-r  and  went  home  without  operation. 

Result — No  report. 

28 


123.  May  19,  1913.    Female — 29.    Admitted  as  an  emergency.    Hysteria. 
Result:    Sept.,    1913 — No    report.     Aug.    24,    1915 — Physician    reports    O  K 
improvement. 

124.  May  19,  1913.  Female — 45.  Hematemesis,  distress  and  vomiting.  Also 
profuse  uterine  hemorrhage  and  abdominal  tumors.  Pre-op.  diag. — 
Ulcer  of  stomach  and  uterine  fibroid.  Op.  (E.  A.  C.  and  G.  W.  M.) 
— No  ulcer.  Hysterectomy  for  multiple  fibroid  tumors.  Appendectomy. 
Comp. — None.  E-d 
Result:  Aug.,  1913 — Progressive  improvement,  but  has  not  yet  re- 
covered from  her  chronic  invalidism.  July  21,  1915 — Still  has  hemop-  E-s? 
tysis,  but  this  is  evidently  not  from  stomach.    Hot  flashes,  indigestion, 

and  general  invalidism.  Not  exam.  Physician  writes  that  patient  died 
June  5,  1916,  of  hemorrhage  from  stomach  and  bowels,  in  spite  of 
transfusion  which  temporarily  did  much  good. 

125.  May  19,  1913.  This  case  and  also  cases  62,  81,  97,  100,  were  tertiary 
cases   treated   with   salvarsan.    All  were  improved.    No  more  cases  of 

this  kind  will  be  accepted.  P-d 

Result:  Sept.  27,  1915— Dr.  B.  reports  that  patient  died  of  specific 
disease  of  spinal  cord. 

126.  May  20,   J 913.     Female— 36.     Three  attacks  of  right-sided  abdominal 
pain.    Pre-op.  diag. — Chronic  appendicitis.    Op.   (G.   W.   M.) — Appen-    ^  ^ 
dectomy.    Freeing  of  abdominal  adliesions.    Comp. — None. 

Result:  Aug.  8,  1916— Dr.  M.  reports,  "Well,  1915." 

127.  May  22,  1913.  Male — 49.  Acute  empyema  of  unknown  origin,  pre- 
ceded by  an  alveolar  abscess.  Condition  very  poor.  Op.  (E.  A.  C.  and 
G.  VV.  M.) — Resection  of  rib  and  drainage.    Comp. — None. 

Result:  Sept.  25,  1913 — Still  discharge  from  wound.    General  condition    P-^ 
excellent.  June  8,  1915 — Later  thoracoplasty  at  P.  B.  B.  HoSp.  Sudden 
collapse  during  dressing  at  dispensary  at  P.  B.  B.  Hosp.    Admitted,    ^ 
case  No.  (2557). 

Result:  Died  twelve  days  later — probably  from  cerebral  embolism  and 
brain  abscess. 

128.  May  23,  1913.    Male— 67.    Right  inguinal  hernia.    Op.    (E.  A.  C.  and 

G.  W.  M.) — Local  anaesthesia.    Ferguson  method.    Comp. — None.  O  K 

Result:  Aug.  9,  1916— Letter— Well. 

129.  May  26,  1913.  Female — 26.  Severe  constant  abdominal  pain  in  lower 
left  quadrant.  Pre-op.  diag. — Chronic  salpingitis  and  retroversion.  Op. 
(G.  W.  M.) — Left  salpingectomy.  Left  oophorectomy,  appendectomy 
and  ventral  suspension.    Comp. — None. 

Result:  Aug.,  1913— Well.    June,  1915— Dr.  M.  reports  patient  better,    E-j 
but  recently  has  had  signs  of  pelvic  inflammation  which  have  subsided. 
Aug.  8,  1916 — Dr.  M.  reports:  "Had  abdominal  pain  for  one  month  in 
January,   1916.    Since  then  has  gained  weight  and  is  well  except  for 
flat  foot." 

130.  May  26,  1913.    Male — 44.    Septic  dog  bite  of  leg  and  popliteal  abscess. 

Op.   (E.  A.  C.) — Incision  and  curettage.    Comp. — None.  O  K 

Result:  Apr.  1,  1916— Letter— Well. 

131.  May  28,  1913.  Male — 52.  Hand  crippled  by  a  painful  swelling  of  the 
tendon  siieaths  of  the  wrist  and  palm  extending  into  the  little  finger. 
Pre-op.  diag. — Tuberculous  tenosynovitis.  Op.  (E.  A.  C.  and  G.  W.  M.) 
— Am])utation  of  little  finger  with  thorough  dissection  of  gelatinous 
tissue  from  tendons  of  palm  and  wrist,  the  annular  ligament  being 
divided.  Closed  without  drainage.  Path,  report  showed  chronic  inflam- 
matory tissue  not  inconsistent  with  a  tertiary  or  tuberculous  lesion. 
Wasserman  reaction  was  positive.    Comp.— None. 

Result:  Aug.  20,  1915 — Well.  Useful  hand  but  ring  finger  does  not  have 
quite  perfect  flexion. 

29 


E-d 


OK 


^^^^xoS^ua^T^^yTo^^nnmeSfi  malt — v^.    night  ingmnal  hernia.    Up.  (G.  W. 
O  K  M.) — Radical  cure  of  right  inguinal  hernia; 

Result:  June,  1915— Well.   (Dr.  M.) 

133.  June  8,  1913.  Male — 68.  Ulcerated  carcinoma  of  floor  of  mouth  at 
frenum  and  attached  to  gum.  Op.  (E.  A.  C) — Wide  excision  of  ulcer- 
ated area  with  removal  of  lA  inches  alveolar  process  and  dissection  of 

O  K  submental   and  submaxillary  glands   through  floor  of  mouth.    Wound 

packed  without  sutures,    Comp. — None. 

Result:  Aug.,  1913 — Well.  Minute  sinus  in  gum.  May  2,  1914 — Re- 
ported to  be  well.    Dec.  9,  1916— Well. 

134.  June  4,  1913.  Male— 69.  Right  inguinal  hernia.  Op.  (E.  A.  C)— 
Bassini.    Double  sac.    Comp. — None. 

Result:  Aug.  23,  1916 — Letter — W^ell.  "My  back  is  about  the  same. 
I  still  play  golf.  Got  90  yesterday  for  18  holes.  Used  to  go  around  in 
the  80's.  My  handicap  is  26.  Play  tennis  also.  That  is  too  strenuous 
for  an  old  chap  of  73." 

136.  June  6,  1913.    Thin  feeble  female — 68.    Marked  visceral  ptosis;  com- 
plaining  of   vague   abdominal  pain  and   distress.     X-ray   exam.,   etc. 
O  K  Operation  not  advised. 

Result:  Aug.  2,  1916 — Physician  reports  that  patient  was  "never  better 
in  her  life."    She  has  never  been  operated  upon. 

136.  June  11,  1913.  M.  female — 48.  General  abdominal  discomfort  and 
nervousness.  Vague  symptoms  which  have  been  called  "sciatica." 
Polypoid  mass  protruding  from  the  cervix  uteri.  Op.  (E.  A.  C.  and 
G.  W.  M.) — Polyp  proved  a  pedunculated  cyst  of  cervical  canal. 
Excised  with  a  portion  of  base.  Plastic  repair  of  cervix.  Comp. — None. 
Path,  report — Benign. 

O  K  Result:  Aug.  21,  191.3 — Much  better,  but  still  has  leucorrhoea.    Aug.  20, 

1915 — Exam. — A  good  cosmetic  result  on  cervix.  Looks  and  feels  well, 
but  "nervous."  No  leucorrhoea.  Aug.  11,  1916 — "Last  winter  I  was 
troubled  some  with  dizziness.  I  saw  a  doctor  who  said  my  blood  pres- 
sure was  forty  above  normal,  but  except  for  that  I  have  been  well. 
I  have  no  pain  or  discharge  of  any  kind,  and  seem  perfectly  well  in  the 
parts  where  I  was  operated  on.  In  fact,  am  better  than  for  a  great 
many  years." 

137.  May  29,  1913.  W.  female— 43.  Widow  of  an  old  patient  of  E.  A.  C.'s 
with  same  disease.  Incipient  tuberculosis.  Slept  on  roof  for  25  days 
pending  admission   to  state  sanitarium.     Con't — Dr.   John   B.   Hawes. 

P-d  July  26,  1915— At  Westfield  State  Sanitarium.    Fairly  comfortable  with 

gas  injections  of  pleural  cavity. 
Result:  Aug.  15,  1916 — Still  under  treatment  at  Westfield  Sanitarium. 

138.  June  21,  1913.  Male — 69.  Indigestion  and  epigastric  pain  for  many 
years.  Pre-op.  diag. — Duodenal  ulcer.  Op.  (E.  A.  C.  and  G.  W.  M.) — 
Post,  gastroenterostomy  for  duodenal  ulcer.  (Anoci.)  Comp. — Serous 
discharge  from  wound  causing  slight  delay  in  healing. 

g.g  Result:  June,  1915 — Well.    Sept.  8,  1916 — Small  hernia  in  scar  which 

is  not  troublesome.  An  attacii  of  "bronchitis"  last  winter  which  left 
him  somewhat  "pulled  down."  Better  now.  No  digestive  symptoms 
when  careful  about  diet. 

139.  June  80,  1913.  Male — 39.  Incompetent  sphincter  ani  due  to  fistula 
operation   many  years   before.     Op.   (E.   A.   C.   and   G.  W.  M.) — Scar 

O  K  excised  and  edges  of  sphincter  approximated.    Comp. — None. 

Result:  Aug.  18,  191.3 — Improved  a  great  deal  but  not  yet  perfect  con- 
trol of  gas.    Apr.,  1916 — Well.    Good  control. 

30 


to  permit  irrigation  of  the  colon  for  chronic  intestinal  stasis,  ihe  open- 
ing had  contracted  and  was  painful.  Op.  (E.  A.  C.)— Novocaine. 
Excision  of  scar  tissue  and  resuture  edge  of  bowel.  Catheter  tied  in. 
Comp. — None.  O  K 

Result:  Sept.,  1913— The  result  of  the  original  operation  has  been 
excellent;  gain  in  weight  and  strength  and  a  sense  of  well-being  having 
replaced  constant  distress,  depression  and  mabiutrition.  The  second 
operation  was  also  efficacious. 

141.  July  8,  1913.  S.  female — 65.  Chronic  indigestion  and  epigastric  pain. 
Stiff  and  painful  rigiit  shoulder.  Pain  in  left  hip.  Pre-op.  diag. — 
Duodenal  ulcer  and  adherent  subacromial  bursitis.    Op.  (E.  A.  C.  and 

G.  W.  M.) — Infolding  ulcer  and  post,  gastroenterostomy.    Manipulation    Q  jj 
of  shoulder.    Comp. — None. 

Result:  Oct.,  1913 — Well  except  for  hip,  which  is  still  troublesome 
(exam.).    Aug.  16,  1916 — Exam. — Well.    Scar  solid. 

142.  July  9,  1913.  Large  well-developed  -male — 45.  Recurrent  attacks  of 
indigestion  and  epigastric  distress.  Pre-op.  diag. — Duodenal  ulcer. 
Op.  (E.  A.  C.  and  G.  W.  M.) — A  contracted  pylorus.  First  portion  of 
duodenum  fixed  high  and  attached  to  gall  bladder  by  adhesions  (con- 
genital). No  ulcer  demonstrable.  Appendix  twisted  and  kinked  and 
wholly  adherent  behind  cecum.  Marked  Lane's  kink  divided  but  no 
plastic  done.  Appendectomy.  Duodenal  adhesions  not  disturbed. 
Comp. — None.  E-d 
Result:  Sept.,  1913 — Well.  July  14,  1915 — Re-entry.  No  abdominal 
symptoms.  For  a  year  has  had  an  indurated  area  in  submaxillary 
region.  Operation  showed  that  this  was  due  to  a  calculus  in  the  sub- 
maxillary gland.    The  gland  and  calculus  were  removed  entire,  under 

the  impression  that  malignancy  or  actinomycosis  existed.  No  comp. 
Path,  report — Sclerosis  of  submaxillary  gland.  July  15,  1916 — Well. 
Scars  normal.    "Nervous." 


143.  July  16,  1913.  M.  female — 47.  Cyst  of  right  lobe  of  thyroid,  size  of 
chestnut.  Op.  (E.  A.  C.  and  G.  W.  M.) — Enucleation  of  cyst.  Comp. 
— None. 

Result:  Aug.  3,  1916 — Letter — "I  have  been  perfectly  well  since  you 
operated,  and  the  scar  is  not  troublesome;  in  fact,  is  almost  indis- 
tinguishable." 


O  K 


144.  July  19,  1913.    Male— 48.    Infected  wound  of  hand.    Op.  (G.  W.  M.)— 
Opening  and  cleaning  wound.    Comp. — Cellulitis  to  elbow.  O  K 
Result:  No  report. 

145.  July  24,    1913.    Male — 43.    Persistent  severe   epigastric  pain.    Pre-op. 
diag. — Cancer  of  stomach.    Op.  (E.  A.  C.  and  G.  W.  M.) — Exploration 
showed  inoperable  cancer  cardiac  end  of  stomach  and  large  multiple    „  . 
soft  metastases  of  liver.    Comp. — Although  nothing  beyond  exploration       "' 
was  attenii)ted,  the  pain  was  greatly  relieved.  p   , 
Result:  The  patient  died  about  2  weeks  after  his  return  home.    Autopsy 
showed  masses  in  liver  to  be  broken  down  malignant  disease.    Primary 
growth  at  cardiac  opening  of  stomach  and  lower  oesophagus. 

146.  July    22,    1913.    Male — 74.     Large   inoperable    cancer   of   the    thyroid 
causing  extreme  dyspnoea  by  displacement  of  the  trachea.    Con't — Dr.    p  j 
C.  A.  Porter.    Op.  was  undertaken  by  Dr.  Porter  as  a  purely  palliative    •c'" 
measure.    Tracheotomy  was  accomplished  by  removal  of  a  portion  of    -g"- 
the  growth.    Comp. — Severe  secondary  hemorrhage  and  sepsis. 

Result:  Died  on  the  tenth  day  (Aug.  3,  1913). 

31 


147.  July  30,   1913.     Male — 9.     Compound   fracture  lower  end  of  humerus. 
E-s?  Op.   (G.  W.  M.) — Cleansing  and  replacement  of  fragments.    Comp. — 

None. 
P-d?  Result:  Aug.  10,  1915 — Mother  reports  a  satisfactory  result  with  some 

(gunstock.')  deformity. 

148.  Aug.  12,  1913.  Male — 63.  Sarcoma  ulria;  size  olive,  previously  incised 
by  another  surgeon.  Amputation  advised  but  refused.  Op.  (E.  A.  C.) 
— Excision  tumor  and  (4  in.)  adjacent  portion  ulna,  with  much  of  sur- 

Q  j^  roimding   soft   parts.    Plastic    on    skin    to    fill    defects.    Comp. — None. 

Path,  report — Giant  celled  sarcoma  of  periosteum,  not  involving  bone. 
Result:  July  29,  1915 — Local  phys.  reports  a  perfect  result;  hand  al- 
most as  strong  as  before  op.  Does  same  work.  Died  July  21,  1916 — 
Death  certificate:  Chronic  nephritis  and  arterio-sclerosis. 

149.  Aug.   13,   1913.    Male — 54.    Recurrent  cancer   of  lip.    Previous  op.    at 
E.C  M.  G.  H.     E.  S.  182344.     Op.  (G.  W.  M.)— V-shaped  excision.    No  dis- 
section of  neck.    Comp. — Stitch  sepsis  and  spreading  of  wound. 
Result:  Aug.  8,  1916— Dr.  M.  reports,  "Well  in  Jan.,  1916." 

150.  Aug.  25,  1913.    Male — 43.    Abscess  of  leg,  opened  and  packed.    Comp. 
O  K            — None. 

Result:  July  20,  1915— Well. 

151.  Sept.  1,  1913 — Female — 46.  Emergency.  Pre-op.  diag. — Acute  cholecyst- 
itis. Op.  (E.  A.  C.) — Revealed  old  and  new  adhesions  about  gall 
bladder,  which  were  not  disturbed  because  pelvic  condition  seemed 
more  urgent.  A  large  pelvic  abscess  was  drained  and  both  tubes  re- 
moved. (Pyosalpingitis.)  Left  ovary  containing  old  hemorrhagic  cyst, 
size  orange,  removed.  (Multilocular  cystoma.)  Uterus,  which  was  large 
and  boggy,  was  curetted.  Adhesions,  causing  partial  obstruction  of 
sigmoid,  divided.  Comp. — Sepsis  from  drainage  area  involved  wound 
slowly,  so  that  it  had  to  be  laid  open  and  packed.  Satisfactory  recov- 
ery.   Re-entry  Jan.  1,  1914,  with  jaundice  and  other  symptoms  justify- 

p__  ing  diagnosis  of  stone  in  common  duct.    Op.   (E.  A.  C.) — A  small  con- 

tracted gall  bladder  containing  a  large  stone  and  connected  by  an  old 
fistula  with  duodenum  (see  Case  24.  This  is  a  second  case  illustrating 
E.  A.  C.'s  explanation  of  Courvoisier's  law).  A  large  stone  was  also 
removed  from  the  common  duct  (?)  through  dense  inflammatory  tissue. 
Cholecystostomy.    Choledochostomy. 

Result:  Julj'^  2.5,  1915 — Letter — Well.  Has  since  had  one  severe  uterine 
hemorrhage.  Aug.  3,  1916 — Well  except  for  irregular  metrorrhagia, 
which  at  times  is  severe.  Abdominal  scar  bulges  throughout.  Uterus 
of  normal  size.  No  abdominal  symptoms.  Digestion  good.  Curetting 
advised  for  probable  uterine  polyp. 

152.  Sept.  7,  1913.  Female — 26.  Extra-uterine  pregnancy.  Op.  (G.  W.  M.) 
— Salpingectomy  (left)  and  removal  of  foetus.    Comp. — None. 

O  K  Result:    Aug.   23,    1915 — Dr.    M.    reports,   "Well,   except    for   chronic 

organic  heart  disease.  Scar  O.  K."  Aug.  8,  1916 — Dr.  M.  reports, 
"Well,  except  for  'heart  trouble'  in  Feb.,  1916." 

158.  Sept.  8,  1913.     Male — 41.     Old  fracture  internal  condyle  femur.    Op. 
(G.  W.  M.) — Removal  of  spicule  of  bone  which  was  causing  annoyance. 
O  K  Comp. — None. 

Result:  Nov.  1,  1918— Well. 


OK 


164.  Sept.   8,   1913.    Female— 25.    Hydramnios.    Op.    (G.  W.   M.)— Delivery 
of  twins.    One  alive  (4  mos.)  and  the  other  macerated.    Comp. — None. 
Death  of  foetus. 
Result:  Nov.  16,  1913— Well. 

82 


165.  Sept.  14,  1913.  Male — 66.  Emergency.  Intestinal  obstruction.  Op. 
(E.  A.  C.) — Gigantic  dilatation  of  a  freely  movable  cecum  of  fetal 
type.  The  appendix  and  tip  of  cecum  were  adherent  at  left  costal 
margin  and  volvulus  had  occurred.  Excision  of  cecum  and  ascending  E-c 
colon  with  a  portion  of  the  ileum.  Lateral  anastomosis.  Drainage  of 
wound  which  was  soiled.  Comp. — Sepsis  in  portion  of  wound  about 
wick;  not  serious. 

Result:  Aug.  17,  1916 — Physician  reports  weU  and  at  work  as  black- 
smith. 

156.  Sept.  15,  1913.  Male — 40.  Persistent  hyperacidity  and  epigastric  pain. 
Pre-op.  diag. — Duodenal  ulcer.  Op.  (E.  A.  C.) — Adhesions  holding 
pylorus  high  under  liver,  thought  to  be  congenital  rather  than  inflamma- 
tory. A  plastic  operation  was  done  to  free  these.  The  appendix  was 
then  found  to  be  adherent  in  pelvis,  and  was  with  great  difficulty  re- 
moved by  enlarging  the  wound  downward.    No  ulcer  was  found.    Comp. 

— Three  successive  pulmonary  emboli.    Slight  sepsis  in  wound  (largely    E-j 
due  to  cough).     Recovery  under   care  of  Dr.  John  B.  Hawes.     This    or 
patient  barely  recovered  from  emboli  and  was  feeble  for  many  weeks.    E-C 
Result:  May,  1915 — Well.    Weak  scar — almost  a  hernia.    July  19,  1915 
— Well.    "About  the  only  unpleasant  result  of  my  illness  is  that  I  am 
somewhat  short  of  my  physical  and  nervous  strength."    Aug.  7,  1916 — 
Telephone — Much    better   than    before   operation,    but   still   occasional 
attacks  of  "acidity,"    Wound  does  not  trouble  him. 

157.  Sept.  16,  1913.    Male — 19.    Tuberculous  cervical  gland  under  angle  of 
right  jaw.    Op.   (E.  A.  C.) — Excision  of  gland.    Comp. — Slight  serous 
discharge.  q  jj 
Result:  Sept.  14,  1915 — Well.    One  small  gland  size  of  pea.    Aug.  22, 

1916 — Letter — No  further  trouble. 

158.  Sept.  23,  1913.  Female— 15.  Chronic  appendicitis.  Op.  (G.  W.  M.)— 
Adherent  appendix  removed,    Comp. — None. 

Result:  Dec.   1,   1913 — Well.    Aug.   17,   1915 — Phys.   reports  occasional    P-d? 
pain  in  right  side.    Aug.  8,  1916 — Dr.  M.  reports,  "Still  has  abdominal 
trouble  and  constipation."    Report  in  May  (Dr.  Boos). 

169.  Sept.  29,  1913.  Female— 45.  Fibroid  of  uterus.  Op.  (G.  W.  M.)  — 
Hysterectomy  and  appendectomy.  C 

Result:  Sudden  death  on  7th  day  from  pulmonary  embolus. 

160.  Oct.  25,  1913.  Female — 60.  Subacromial  bursitis  (adherent).  Op.  (E. 
A.  C.) — Adhesions  broken  under  ether  without  incision.  Abduction 
maintained  ten  days. 

Result:  July  1,  1915 — Well.    Convalescence  was  slow  and  painful.    Re-    Q  K 
cently  (sciatica),  but  shoulder  is  well.    See  Case  W.  S.  202633,  Mass. 
Gen'l  Hosp.  records.    July  24,  1916 — Sacro-iliac  symptoms  passed  away 
spontaneously.    No  further  trouble  with  shoulder, 

161.  Nov.  3,  1913.    Male— 34,    Drug  habit.    No  operation. 

162.  Nov,  17,  1913,  Male— 33.  Salvarsan.  Under  care  of  Dr.  Wm.  F.  Boos. 
Result:  July  31,  1916— Dr.  B.  reports,  "Well."  O  K 

163.  Nov.    18,    1913.     Male— 32.     Chronic   appendicitis.    Op.    (E.    A.    C.)- 
Strictured  appendix  removed.    Comp. — None. 

164.  Dec.  14,  1913.    Female — 25.    Ureteral  catheterization.    X-rays,  etc.,  for 
diagnosis.     Intermittent     hydronephrosis    (?).     Chronic     endometritis. 
Fissura  ani.    Refused  operation.    Later  curettage  of  uterus  and  dila-   p_r 
tation  of  anus  by  her  own  physician. 

Result:  Unknown. 

166.  Dec.  21,  1913.    Emergency  case  of  syncope.    Pulmonary  tuberculosis. 

Remained  in  hosp.  over  night.  q  jr 

Result:  No  report. 

33 


OK 


166.  Dec.  26,  1913.  Female — 35.  Acute  appendicitis.  Under  the  care  of 
Dr.  Ed.  P.  Richardson.    Op.  (E.  P.  R.) — Appendectomy.    No  drainage. 

O  K  Comp. — None. 

Result:  Sept.  9,  1915 — Scar  solid.  Well  except  for  constipation,  which 
was  present  before  op.    June  2,  1916 — Died  of  acute  nephritis. 

167.  Dec.  30,  1913.  Female— 40.  Prolapse  of  uterus.  Op.  (E.  A.  C.)— Ap- 
pendectomy (normal).  Hysterectomy  by  Crile's  method  for  prolapse. 
Comp. — None.  Oct.  16,  1914 — Cystocele  which  protrudes  when  recum- 
bent, but  disappears  when  standing.    Remaining  ovary  tender;  size  of 

E-j  golf  ball.    Some  vague  discomfort,  but  practically  well. 

Result:  Sept.  24,  1915 — Husband  reports  patient  well  except  for  occa- 
sional pain  in  side.  Feb.  25,  1916 — Condition  same.  June  23,  1917 — 
Small  abscess  has  recently  come  in  abdom.  scar  and  discharged  several 
silk  sutures. 

168.  Dec.  31,  1913.  Female — 35.  Prolapse  of  uterus;  uterine  polyp;  perineal 
lacerations.  Op.  (E.  A.  C.) — Hysterectomy  and  fixation  of  vaginal 
stump  to  abdominal  wall.  Appendectomy  (ap.  contained  pus  and  pin- 
worms).    Extensive  perineal  lacerations  not  repaired  owing  to  patient's 

O  K  poor  condition.    Comp.— None. 

Result:  July  31,  1915 — Well.  No  abdominal  symptoms.  Scar  O.  K. 
When  recumbent,  cervix  is  low,  but  when  standing  is  very  high.  Chief 
complaint  now  is  pruritus  vulvae,  which  was  present  before  operation 
and  is  occasionally  still  troublesome.  Pinworms?  Perineal  repair  not 
necessary.    Aug.  14,  1916 — Letter — Well,  except  for  pruritus  ani. 

169.  Dec.  81,  1913.    Male— 53.    Double  inguinal  hernia.    Op.    (G.  W.  M.)— 
O  K  Double  Bassini.    Comp. — None. 

Result:  No  report. 

170.  Jan.  5,  1914.    Male— 29.    Varicocele.    Op.  (G.  W.  M.)    Comp.— None. 
O  K  Result:  Aug.  18,  191.5— Friend  reports,  "Well." 

171.  Jan.  7,  1914.  Male — 20.  Feruncie  on  elbow.  Lymphangitis.  No.  op. 
Jan.  15,  1914,  and  Feb.  8,  1914 — Re-entries  for  other  feruncles.  Treated 
by  Dr.  A.  E.  Steele  with  vaccines. 

O  K  Result:  July  27,  1915 — Patient  convinced  that  vaccines  caused  improve- 

ment. July  31,  1916 — Re-entered  with  a  septic  pilonidal  sinus  which 
has  troubled  him  since  January.  Sinus  excised  with  local  anaesthesia. 
Still  has  some  acne  and  constipation.    Dec,  1916 — Exam. — Well. 

172.  Jan.  8,  1914.  Male — 40.  Left  varicocele  and  enlarged  ext.  ring  almost 
amounting  to  hernia.    Weak  right  ing.  ring.    Chronic  epididymitis.    Op. 

Q  j^  (E.  A.  C.) — Excision  of  varicocele  and  Ferguson  operation  for  hernia 

without  ligation  of  sac.    Comp. — None. 
Result:  Aug.  3,  1916— Letter— Well. 

173.  Jan.  12,  1914.    Female — 49.    Cancer  of  stomach.    Case  No.  869  at  Peter 
E.(l  Bent   Brigham   Hospital,  where   operation   had  been   advised   against. 

Op.  (E.  A.  C.) — Local  anaesthesia.    Exploration.    Condition  inoperable. 
P-d  Comp. — None. 

Result:  Died  Sept.  17,  1914. 

174.  Jan.  13,  1914.  Female — 35.  Fibro-cystic  tumors  of  right  breast.  Men- 
orrhagia. Op.  (E.  A.  C.) — Excision  of  mammary  gland  through  Warren 
incision.    Comp. — Collection  of  serum  twice  evacuated  by  director. 

E-c?  Result:  Aug.  6,  1915 — Scar  O.  K.,  but  the  artificial  breast  has  disap- 

peared.    Menorrhagia.     May  15,   1916 — Scars   of  operation  O.  K.     No 

O  K  further  trouble.    Still  has  menorrhagia  and  indigestion.    Recently  dis- 

located right  internal  semilunar  cartilage.    Treated  conservatively  by 
E.  A.  C. 
176.  Jan.  22,  1914.    Male— 26.    Chronic  appendicitis.    Op.    (E.  A.  C.)— Ap- 
pendectomy   under    local    anaesthesia.    Strictured    appendix.    Comp. — 

O  K  None. 

Result:  Aug.  7,  1916 — Physician  reports,  "Well." 

84 


E-s 


OK 


P-d 


176.  Jan.   27,    1914.    Female — 29.    Prolapse   of  uterus   recurrent   after   two 
previous   operations.    Op.    (G.  W.   M.) — Ventral  fixation;  double  sal-    „ 
pingectomy;  appendectomy;  perineorrhaphy.    Comp. — Sepsis  in  abdom- 
inal fat. 

Result:  July,  1915 — Well.  Exam,  by  Dr.  M.  Scar  solid.  Uterus  in 
good  position.    Aug.  8,  1916 — Dr.  M.  reports,  "Slight  cystocele." 

177.  Jan.  27,  1914.  Female — 26.  Middle  ear  abscess.  No  operation.  Under 
the  care  of  Dr.  T.  J.  Shanahan. 

Result:  Aug.  3,  1915 — Letter  from  Dr.  S.  says,  "Hearing  is  O.  K.  and 
no  subjective  symptoms." 

178.  Jan.  29,  1914.  Female — 26.  Persistent  albuminuria,  without  other 
symptoms  of  nephritis.  Pain  in  right  side  of  abdomen  and  back.  X-ray 
showed  distinct  round  shadow  in  neighborhood  of  right  ureter  near 
bladder.  Ureteral  catheterization  by  Dr.  Young,  who  diagnosed  sus- 
picious shadow  as  phlebolith.  Op.  (E.  A.  C.)  on  diagnosis  of  chronic 
appendix  and  possible  ureteral  calculus.  A  strictured  appendix  re- 
moved and  also  a  phlebolith  which  lay  in  direct  contact  with  ureter. 
Comp. — None. 

Result:  Aug.  1,  1915 — Free  from  all  pain  since  operation,  but  slight 
albuminuria,  without  renal  sediment,  persists.  July  27,  1916 — Has  had 
a  severe  nervous  breakdown,  due  possibly  to  the  nephritis,  which  is 
worse.  Is  in  charge  of  Dr.  Henry  A.  Christian,  Peter  Bent  Brigham 
Hospital  (No.  7835),  for  nephritis.  No  symptoms  like  those  for  which 
she  was  operated  upon.    Feb.,  1917 — Back  at  work.    Feels  well. 

179.  Jan.    29,    1914.    Female — 45.    Pre-op.    diag. — Acute    appendicitis.    Op. 

(G.  W.  M.) — Appendix  was  obliterated  and  retrocecal.     Removal  of    E-d 
pyosalpynx  size  fist.    Comp. — None. 

Result:  June,  1915 — Hernia  site  of  drainage.    Otherwise  well.    (Dr.  M.)    E-s? 
Aug.  8,  1916 — Dr.  M.  reports,  "Large  hernia." 

180.  Feb.   3,   1914.    Male — 40.    Renal  colic.    X-ray  showed  no  stone.    Pain 
soon  subsided.    No  op.  O  K 
Result:  Aug.  5,  1915 — Letter — Well.    No  other  attacks. 

181.  Feb.  8,  1914.    Male — 25.    Dislocation  of  semilunar  bone  of  wrist.    Op. 

(G.  W.  M.) — Excision  of  semilunar  bone.    Comp. — None.  /-v  j^ 

Result:  Aug.  9,  1915 — Dr.  M.  reports,  "Useful  wrist  with  sKght  pain 
on  forced  extension." 

182.  Feb.   8,   1914.    Male — 38.    Acute   appendicitis   and  general   peritonitis. 
Op.  (G.  W.  M.) — Gangrenous  appendix  removed.  Drainage.    Comp. — 
None.  O  K 
Result:  Nov.  1,  1916— Physician  reports,  "Well." 

183.  Feb.  10,  1914.     Male— 35.     Acute  appendicitis.     Op.   (G.  W.  M.)— Ap- 
pendectomy.   Drainage.    Comp. — None.  O  K 
Result:  Aug.  8,  1916— Dr.  M.  reports,  "Perfectly  well  in  June,  1916." 

184.  Feb.  12,  1914.    Female.    Glossitis.    No  op.    Under  care  of  Dr.  G.  W.  M.    q  ^ 

Result:  No  report. 

185.  Feb.  16,  1914.    Female— 51.    Pre-op.  diag.— Cholecystitis.    Op.   (G.  W. 

M.) — Cancer  of  the  liver.    Inoperable.    Comp. — None.  P-d 

Result:  No  report. 

186.  Feb.  18,  1914.  Male — 47.  Epithelioma  of  nose  near  inner  canthus  of 
eye.  Op.  (E.  A.  C.  and  G.  W.  M.) — Excision  of  growth  and  closure 
of  defect  by  transplantation  of  flap.  Comp. — Slight  parting  of  edge  of 
flap.  E-s 
Result:  Aug.  29,  1915 — Scar  barely  visible.  No  evidence  of  recurrence. 
Tear  duct  displaced  about  1  mm.,  so  that  it  does  not  functionate.  '  Bit 

of  int.  canthus  excised  and  a  stitch  put  in  to  turn  tear  duct  in  right 

85 


place.  Choleision  (?)  to  outer  side  duct.  Aug.  5,  1916 — Physician  re- 
ports, "A  perfect  result."    No  further  trouble  with  the  tear  duct. 

187.  Feb.  28,  1914.    Female— 37.    Septic  finger.    Op.   (G.  W.  M.)— Incision 
O  K            and  drainage.    Comp. — None. 

Result:  No  report. 

188.  Mar.  6,  1914.  Female — 34.  Obstructive  jaundice.  Fre-op.  diag. — Stone 
in  common  duct.  Op.  (E.  A.  C.) — Two  stones  impacted  in  a  fistula 
between  contracted  gall  bladder  and  duodenum.  Another  in  common 
duct  fixed  in  papilla.  A  large,  firm,  elastic  mass  in  region  of  head  of 
pancreas — considered  malignant.  Transduodenal  choledochostomy  with- 
out drainage.  Stones  removed  from  fistula  and  from  common  duct 
were   all   three   of  the   small   mulberry   variety.    (This   therefore  is    a 

O  K  further  proof — and  a  most  convincing  one — that  contracted  gall  bladder 

will  generally  be  found  connected  with  the  gut  by  old  fistulse  if  a  stone 
is  present  in  the  common  duct.)  (See  cases  24  and  151.)  (This  opera- 
tion was  done  under  the  principles  of  anoci  association  and  there  was 
no  post-operative  pain.  On  the  fourth  night  she  went  without  permis- 
sion to  the  bathroom  alone,  defecated  and  returned  to  bed!)  Comp. — 
None. 

Result:  July 30,  1915 — Letter — Well.  Has  girl  four  months'  old.  Aug.  7, 
1916 — Friend  reports  that  she  is  well. 

189.  Mar.  10,  1914.  Male — 50.  Chronic  indigestion,  with  vague  symptoms. 
Pre-op.  diag. — 1.  Gallstones.  2.  Duodenal  ulcer.  3.  Chronic  appendi- 
citis. 4.  No  pathology.  Op.  (E.  A.  C.) — A  strictured  appendix  adher- 
ent throughout  in  pelvis.  A  very  long  Lane's  kink.  Pyloric  region 
normal  except  for  (congenital?)  adhesion  between  pylorus  and  gall 
bladder.  This  '"as  not  disturbed.  Pjioric  sphincter  was  tight  so  that 
it  was  stretched  by  inversion.  The  sigmoid  was  so  tightly  adherent  to 
rectum  that  it  could  not  be  freed  without  making  a  second  incision. 

E-d  There  was  also  a  typical  Jackson  membrane  constricting  the  ascending 

colon  and  evidently  obstructing  cecum  to  a  certain  extent.    This  was 

P-d  divided   and  rearranged.    Comp. — Excessive  post-operative  vomiting — 

old  blood  on  second  day.    Sepsis  in  abdominal  fat  without  temp,  (due 

E-c  to  persistent   vomiting?),  phlebitis   calf  of  leg;   hiccough;  distressing 

convalescence. 

Result:  Aug.  6,  1915 — Looks  well.  Weight  same.  No  material  benefit 
from  operation  except  much  less  vomiting.  Still  has  acidity,  constipa- 
tion, and  flatulence.  Scar  solid,  but  internal  fibres  of  rectus  are 
paralyzed.  June  30,  1916 — Not  well.  Has  sensation  of  distention  in 
left  iliac  fossa,  and  headaches.  Proctoscopy  advised.  Oct.  14,  1916 — 
Died.  Death  certificate:  Septic  endocarditis.  Septic  bronchitis,  pleurisy 
with  effusion. 

^  jy^    190.  Mar.  22,  1914.    Male— 30.    Grippe.    24-hour  rest  in  bed. 
^  ^  Result:  July  1,  1915— Well.    Aug.  8,  1916— Well. 

191.  Mar.  24,  1914.  Male — 36.  Calcified  deposit  in  supra-spinatus  tendon 
causing  subacromial   bursitis.    Op.    (E.   A.   C.) — Removal  of   deposit. 

O  K  Comp. — None. 

Result:  Aug.  5,  1916— Letter— Well. 

192.  Apr.    6,    1914.    Male — 36.    Chronic    a])pendicitis    and    movable   kidney. 
O  K  Op.   (G.  W.  M.) — Appendectomy.    No  op.  on  kidney.    Comp. — None. 

Result:  Aug  19,  1915 — Dr.  M.  reports,  "Patient  well." 

193.  Apr.  10,  1914.  Female— 39.  Empyema  of  left  antrum.  Op.  (Dr.  D.  C. 
Greene) — Resection  of   anterior   end  of  left   lower   turbinate  and   re- 

E-s  section  of  part  of  naso-antral  wall.    Comp. — Septic  al)sorption.    Fever 

suljsided  on  6th  day.  Re-entry  on  June  25,  1914 — Double  femoral  hernia 
and  recent  symptoms  of  acute  appendicitis.    Op.   (E.   A.  C.) — Gibson 

36 


incision.  A  thick,  partially  obliterated  appendix  removed.  Both  herniae, 
which  were  rather  weak  rings  than  true  herniae,  were  repaired  from 
inside  through  same  incision.    Comp. — None. 

Result:  Aug.  24,  1915— Well.  Scar  solid.  Left  hernia  bulges  on  cough- 
ing. Still  has  nasal  symptoms  and  occasional  free  dripping  of  pus  from 
antrum (?).    Aug.   2l",    1916 — Exam. — Well.    Condition  same. 

194.  Apr.   10,   1914.    Male — 20.    Septic  pilonidal  sinus  ten  inches  long.    Op. 

(E.  A.  C.) — Excision  of  sinus.    Wound  packed.    Comp. — None.  O  K 

Result:  Apr.  9,  1916— Exam.— Well. 

195.  Apr.  14,  1914.  Male — 53.  Pre-op.  diag. — Duodenal  ulcer  with  stenosis. 
Op.  (E.  A.  C.) — Duodenal  ulcer  and  also  a  large  indurated  ulcer  of 
lesser  curvature.  Partial  gastrectomy  by  E.  A.  C.'s  method.  Comp. — 
None.  .  O  K 
Result:  July  28,  1915 — Well.  Scar  solid.  For  a  long  time  after  opera- 
tion had  a  peculiar  numb  sensation  in  left  leg,  above  and  to  outer  side 

of  knee.  This  has  now  almost  disappeared.  Somewhat  careful  of  diet, 
but  eats  nearly  everything.    Aug.  14,  1916 — Exam. — Well. 

196.  Apr.  16,  1914.  Female — 43.  Fecal  fistula  following  drainage  of  a  pelvic 
abscess  by  another  surgeon.  Fistula  reduced  to  a  pinhole  sinus  under 
expectant  treatment,  but  when  patient  went  to  work  again  it  enlarged  g_j 
and  became  troublesome.  The  fistula  was  successfully  excised  by  Dr. 
John  Homans  at  Peter  Bent  Brigham  Hosp.,  Sept.  17,  1914.  (No. 
3189.) 

Result:  Aug.  24,  1916— Letter— Well. 

197.  Apr.  21,  1914.  Female— 32.  Cystic  lymphoma  of  neck.    Op.  (G.  W.  M.) 

— Incision  and  evacuation  of  clear  fluid.    Comp. — None.  P-d 

Result:  Died  at  B.  C.  H.,  July  24,  1915.   (No.  323,711.)   Cancer  of  lungs. 

198.  Apr.  28,  1914.    Male — 42.    Malunion  of  CoUes  fracture  with  great  dis- 
tortion.   Also  fracture  of  carpal  scaphoid.    Op.    (E.  A.   C.) — Excision 
of  lower  fragment,  refracture  and  partial  correction  of  displacement. 
Comp. — None.    There  was  a  very  decided  improvement  manifest  two    E-s 
months  after  the  operation. 

Result:  Sept.  3,  1915 — Wife  writes,  "I  am  sorry  to  tell  you  not  a  good 
hand;  very  crooked  and  stiff." 

199.  May  1,  1914.    Female — 19.    Right  inguinal  hernia.    Weak  left  ring.    Op. 
(E.  A.  C.) — Ferguson  operation  on  right.    Tightening  of  left  inguinal 
ring.     Slight  sepsis  in  fat  on  both  sides.     No  temp.     Both  healed  on    E-c 
14th  day. 

Result:  July  24,  1915— WeU.  Scar  O.K.  Aug.  15,  1916— Seen  recently 
by  physician.    Well. 

200.  May  4,  1914.    Male — 46.    Pre-op.  diag. — Acute  appendicitis,  also  chronic 
diverticulitis  of  sigmoid  (?).    Op.   (E.  A.  C.) — A  strictured  appendix, 
distended  with  pus,  removed.    Epiploicae  of  sigmoid  were  adherent  in 
pelvis  and  one  shot-like  body,  probably  in  diverticulum,  was  felt.  Comp.    O  K 
None. 

Result:  Aug.  19,  1915 — Phys.  reports  that  patient  is  well  except  for 
"catch  in  side  when  he  raises  his  arms  above  his  head."  Dec.  31,  1915 
— Died  of  pneumonia. 

201.  May  18,  1914.    Male — 53.    Bronchopneumonia.    Comp. — None. 

Result:  July  20,   1915 — Well,  except  slight  chronic  cough.     No  worse    q  jj 
than  before  pneumonia.    July  15,  1916 — Well. 

202.  May  20,  1914.    Male— 28.    Subsiding  acute  appendicitis.    Op.  (E.  A.  C.) 

— Appendectomy.    Drainage.    Comp. — None.  O  K 

Result:  Sept.  1,  1916— Letter— Well. 

203.  May  24,  1914.    Female— 33.    Gallstones  in  gall  bladder.    Op.  (E.  A.  C.) 

— Cholecystostomy.    Comp. — None.  O  K 

Result:  Aug.  1,  191.5 — Well,  but  nervous.  Jime,  1916 — Has  had  no  more 
symptoms  of  gallstones. 

37 


204.  June  2,  1914.  Male — 48.  Pre-op.  diag. — Duodenal  ulcer  with  grave 
doubts  of  cancer.  Op.  (E.  A.  C.) — Ulcerated  cancer  of  pyloric  end 
of  stomach;  partial  gastrectomy  by  E.  A.  C.'s  method.  Comp. — None. 
Re-entry,   July    17,   1915 — Looks    and    feels   much   better   than   before 

pj  previous  op.,  but  for  last  three  months  has  lost  weight  and  had  some 

vomiting.  Op.  (E.  A.  C.) — Recurrence  in  liver  and  glands.  Inop. 
Comp. — None. 

Result:  June  10,  1916 — Physician  reports  that  he  is  still  alive;  that  he 
complains  of  adhesions  and  of  pain  around  the  wound.  Dec.  19,  1916 — 
Died. 

205.  June  2,  1914.  Male — 39.  Acute  subacromial  bursitis  from  calcification 
in  supraspinatus  tendon.  Op.  (E.  A.  C.) — Incision  of  bursa  and  re- 
moval of  deposit.    Comp. — None. 

O  K  Result:  Aug.  2,  1915 — Practically  well.    Some  discomfort  in  extremes 

of  motion.  Aug.  2,  1916 — -"My  shoulder  presents  practically  a  perfect 
End  Result.  I  cannot  throw  anything  without  pain,  but  otherwise  it 
is  all  right." 

206.  June  4,  1914.  Male— 21.  Pre-op.  diag. — Periostitis  of  ankle.  Op.  (G. 
_  _  W.  M.) — Incision  and  drainage  of  abscess  (due  to  osteomyelitis?). 
'-'  *^  Comp.— None. 

Result:  No  report. 

207.  June  4,  1914.  Male — 31.  Under  care  of  G.  W.  M.  Sacro-iliac  strain. 
O  K  Plaster  support  applied. 

Result:  No  report. 

208.  June  5,  1914.  Female — 20.  Pre-op.  diag. — Lacerated  cervix.  Salpin- 
gitis.    Op.   (G.  W.  M.) — Trachelorrhaphy.    Uterus  suspended  by  round 

^  *^  ligaments.    Strictured  appendix  removed.    Comp. — None. 

Result:  No  report. 

209.  June  8,  1914.  Male — 32.  Traumatic  paralj'sis  and  neuritis  of  ulna 
O  K  nerve.    Under  care  of  G.  W.  M. 

Result:  Aug.  25,  1915 — Patient  writes  Dr.  M.  that  he  has  recovered. 

210.  June  9,  1914.  Male — 50.  Multiple  contusions  from  falling  35  feet. 
O  K  Under  care  of  G.  W.  M. 

Result:  Aug.  17,  1915— WeU.    (Letter.) 

211.  June  14,  1914.  Female — 44.  Pre-op.  diag. — Strictured  appendix;  pos- 
sibly gallstones  also;  pelvic  adhesions.  Op.  (E.  A.  C.)— Obliterated 
appendix  removed.    Marked  Lane's  kink  present,  but  no  plastic  done. 

O  K  There  were  also  pelvic  adhesions  of  omentum  and  a  fibroid  on  the  uterus 

the  size  of  a  horse  chestnut.  These  pathologic  conditions  not  removed 
because  symptoms  amply  accounted  for  by  condition  of  appendix. 
Comp. — None. 

Result:  Aug.  1,  1915— Letter  to  brother,  a  physician,  "Well."  Aug.  15, 
1916 — Letter  to  physician  within  a  few  months,  "Well." 

212.  June  15,  1914.  Male— 58.  Pre-op.  diag.— Duodenal  ulcer;  possibly  gall- 
stones. Op.  (E.  A.  C.)— "Tucked  up"  posterior  duodenal  ulcer.  Pos- 
terior gastro-enterostomy.  Gall  bladder  seemed  norma],  but  at  one  time 
there  was   a  suspicious  feeling  of  elusive  stones.     Owing  to  patient's 

O  K  condition,  it  was  felt  unwise  to  add  to  shock  of  operation  by  explora- 

tion.   Comp. — None. 

Result:  Dec.  28,  1914— Went  to  work  one  month  after  operation  and 
has  worked  steadily  ever  since.  Eats  and  sleeps  well,  but  complains 
of  vague  indigestion  (due  to  gallstones?).  Nov.  20,  1916— Physician 
reports,  "Well." 

213.  June  17,  1914.  Male— 57.  Double  femoral  incarcerated  hernijE.  Op. 
(E.   A.   C.)— E.  A.   C.'s  method  on  left.     Simple  operation  on   right. 

O  K  Comp. — None. 

Result:  Aug.  6,  1915— Well.  Recently  examined  by  phys.  Aug.  17, 
1916 — Physician  reports,  "Well." 

88 


214.  Male — 24.    Septic  wound  of  foot  with  inguinal  adenitis.    Under  care  of 

G.  W.  M.    No  operation.  O  K 

Result:  No  report. 

215.  June  27,  1914.  Female — 68.  Pre-op.  diag. — Duodenal  ulcer  with  steno- 
sis, possibly  cancer  of  pyloric  end  of  stomach.  Op.  (E.  A.  C) — Duo- 
denal and  also  gastric  ulcer  adherent  to  pancreas.    Partial  gastrectomy 

by  E.  A.  C.'s  method.    A  superficial  layer  of  pancreatic  tissue  was  re-    O  K 
moved  with  ulcer.    Comp. — None. 

Result:  July  29,  1915— Well.  May  24,  1916— Scar  solid.  Digestion  good. 
Gain  of  25  pounds.    Bowels  normal. 

216.  June  29,  1914.  Male — 38.  Subacromial  bursitis  due  to  calcification  in 
supraspinatus  tendon.  Op.  (E.  A.  C.) — Removal  of  calcareous  deposit. 
Comp. — None. 

Result:  July  27,    1915— Well.     Aug.  2,   1916— "Shoulder  seems   to   be    q  g 
absolutely  well,  and  all  its  motions  are  normal."    Oct.  25,  1916 — Exam. 
— Shoulder  which  was  operated  upon  has  remained  well,  but  has  pain 
and  discomfort  in  other  (left)  shoulder.    Symptoms  too  mild  to  warrant 
operation. 

217.  July  7,  1914.  Male— 30.  Abscess  of  buttocks.  Op.  (G.  W.  M.)— Incision 

and  drainage.    Comp. — None.  O  K 

Result:  No  report. 

218.  July  21,  1914.  Male — 58.  Adeno-carcinoma  of  ant.  wall  of  rectum. 
Proctoscopy  by  E.  A.  C.  Referred  to  Dr.  D.  F.  Jones  for  operation. 
Operated  on  by  Dr.  J.  at  Deaconess  Hospital  by  Dr.  J.'s  two-stage 
method.  Comp. — Fecal  leakage  of  perineal  suture  which  healed  in  a 
few  weeks. 

Result:  Aug.  2,  1915 — Gained  30  pounds.  Incontinence  of  feces  requir- 
ing change  of  dressing  3  to  5  times  daily.  Physical  strength  good,  but 
endurance  poor.  Aug.  7,  1916 — Letter — "There  has  been  no  indication 
of  a  return  of  the  malady  that  was  the  cause  of  the  operation  two 
years  ago.  There  has  not  been  much  change,  but  some  improvement.  E-s 
My  weight  remains  25  pounds  above  normal.  The  urinary  system  is 
nearly  normal.  There  is  no  action  to  the  generative  organs.  My 
strength  has  increased  somewhat,  and  endurance  considerably  recently. 
My  greatest  inconvenience  is  the  lack  of  action  of  the  muscle  of  the 
anus,  generally  three  changes  of  the  back  dressing  a  day  is  all  that  is 
required;  but  if  my  employment  calls  for  much  heavy  lifting,  it  seems 
as  though  there  was  no  muscle  at  all;  usually  a  large  proportion  of 
fecal  matter  is  voided  naturally.  It  may  be  because  of  the  changed 
condition,  but  it  seems  as  though  there  was  more  gas  than  natural  from 
the  bowel." 

219.  Sept.  16,  1914.  Male — 32.  Recurrent  attacks  of  abdominal  pain  and 
diarrhoea.  Partial  obstruction  of  sigmoid  flexure  demonstrated  by 
X-ray.  Op.  (E.  A.  C.) — Obstruction  was  due  to  adhesion  of  sigmoid 
to  its  own  mesentery.  This  was  satisfactorily  relieved  by  plastic  opera- 
tion. A  strictured  appendix  was  also  removed  through  the  same  in-  O  K 
cision.    Comp. — None. 

Result:  Aug.  2,  1915 — Perfectly  well  until  a  week  ago,  when  he  had 
"one  of  the  old  attacks,"  which  his  doctor  said  was  "colitis."  Aug.  9, 
1916 — Father  reports  that  he  is  better  than  he  was. 

220.  Sept.  26,   1914.    Male— 19.    Acute  appendicitis.    Op.    (E.   A.   C.)— Ap- 
pendix gangrenous  with  large  concretion.    Appendectomy  and  drainage. 
Comp. — None.  p.  U 
Result:  Aug.  19,  1915 — Exam. — A  large  bulging  scar.    Well.    Nov.  28, 

1916 — Exam. — Well.  Scar  is  so  weak  as  to  be  practically  a  hernia. 
Radical  cure  advised. 

89 


Ml.  Oct.  3,  1914.  Female — 57.  Emergency  case  in  poor  condition.  Pre-op. 
diag. — Cholecystitis  with  impaction  of  stone  in  cystic  duct.  Op.  (E.  A. 
C.) — Local  anaesthesia.  Many  small  stones  removed  from  gall  bladder. 
Cholecystostomy.  Condition  too  poor  to  admit  further  exploration. 
Comp. — Persistent  biliary  fistula;  phlebitis  in  large  varicose  veins  of 
left  leg.  Re-entry  Dec.  1,  1914^Biliary  fistula;  white  stools;  chills. 
Pre-op.  diag. — Stone  in  cj'stic  duct  pressing  on  common  duct.  Op.  (E. 
A.  C.  and  Dr.  W.  W.  Harvey) — A  stone  was  found  impacted  firmly 
in  ampulla  (it  seemed  as  if  it  would  have  been  impossible  for  bile  to 
pass  this  obstruction,  yet  bile  had  been  present  in  the  stools,  and  at 
times  the  fistula  had  closed,  and  there  was  only  slight  jaundice.)  Trans- 
duodenal choledochostomy  and  removal  of  another  large  stone  as  well 
as  that  impacted.  The  common  duct  also  contained  pus  and  granular 
detritus  and  probably  other  small  stones.  Following  Moynihan's  prin- 
ciple,  that  when  the  largest  stone  has  been  removed  by  this  method 
*^***  it  is  unnecessary  to  try  for  other  stones  or  institute  drainage  in  the 

duct,  the  incision  in  the  anterior  duodenal  wall  was  closed.  The  gall 
bladder  was  temporarily  clamped  to  insure  drainage  of  bile  into  the 
intestine  until  the  duct  was  flushed  out.  (The  clamp  was  removed  on 
the  5th  day.)  Comp. — None.  Convalescence  was  normal  after  the 
patient's  return  home  until  the  spring  of  1915,  when  ascites,  oedema 
of  the  legs,  and  abdominal  symptoms  developed.  She  was  taken  in  a 
critical  condition  to  the  Peter  Bent  Brigham  Hosp.  (No.  5247),  and 
was  operated  on  by  Dr.  John  Romans,  who  was  kind  enough  to  ask 
the  writer  to  see  her.  Exploratory  operation  showed  no  definite  cause 
for  symptoms,  which  were  probably  circulatory.  The  lower  edge  of  the 
liver  was  adherent  to  the  abdominal  wound,  and  was  buckled  on  itself, 
but  this  did  not  explain  the  symptoms. 
Result:  She  died  within  12  hours  and  no  autopsy  was  obtained. 

222.  Oct.  6,  1914.  Stout  male — 45.  Acute  intestinal  obstruction  from  ad- 
hesions at   old   appendectomy  scar    (interval   operation   by  Dr.   F.   B. 

^  |,  Harrington  in  1897  (?)  ).    Op.  (E.  A.  C.) — Novocaine  and  a  few  whiffs 

of  ether.    Division  of  multiple  adhesions  and  freeing  of  an  angulated 
obstruction  of  the  small  intestine.    Comp. — None. 
Result:  July  26,  1916— Exam.— Well.    Scar  solid. 

223.  Oct.  9,  1914.  Female — 44.  Chronic  pain  in  right  inguinal  region  and 
tenderness  at  McBurney's  point.  Hypertrophied  cystic  cervix.  Pre-op. 
diag. — Chronic  appendicitis  and  cyst  of  cervix  uteri.  Op.  (E.  A.  C) — 
Appendectomy  (terminal  obliteration  of  appendix).  Ant.  lip  of  cervix 
amputated.  Comp. — None.  Mar.  25,  1915 — Re-entry  for  acute  hemor- 
rhagic cystitis  of  unknown  origin  (colon  bacillus).  There  had  been 
no  previous  symptoms  of  cystitis  and  no  catheter  or  other  instrument 
had  ever  been  passed  into  the  bladder.  There  was  no  pain,  frequency, 
or  the  usual  irritation  of  the  bladder  characteristic  of  cystitis.  Dr.  J.  D. 
Barney  in  consultation  catheterized  ureters  and  obtained  normal  sterile 

gj  urine   from  both.    The  mucosa  of  the  bladder  showed  small  punctate 

hemorrhagic  areas.  Apparently  this  was  a  case  of  acute  haematogenous 
infection  of  the  bladder  witiiout  involvement  of  the  kidneys.  At  this 
time  the  posterior  lip  of  the  cervix  was  found  to  have  greatly  enlarged 
and  to  have  become  as  cystic  as  the  anterior  lip  had  been.  The  opera- 
tion on  the  cervix  had  therefore  been  of  little  value.  The  inguinal  and 
abdominal  symptoms  had,  however,  been  entirely  relieved. 
Result:  Aug.  10,  1915 — Well.  Urine  perfectly  clear.  Scar  solid.  Cer- 
vix smooth  and  less  cystic.  Oct.  2.3,  1915 — Small  epithelioma  removed 
from  forehead  under  local  anaesthesia.  Jan.  6,  1917 — Well.  Abdominal 
scar  somewhat  pigmented  and  keloidal,  but  strong.  Few  small  cysts  in 
cervix. 

224.  Oct.  17,  1914.  Male — 46.  Repeated  attacks  of  typical  gallstone  colic 
during  last  five  years.    Fever.    Slight  jaundice.    Op.  (E.  A.  C.  and  Dr. 

40 


A.  W.  Reggio) — Whole  upper  right  quadrant  was  bound  in  a  hard  mass 
the  size  of  an  orange.  This  seemed  inflammatory  rather  than  malig- 
nant. Slow,  blunt  dissection  into  this  mass  led  into  an  abscess  con- 
taining thick  pus.  Further  exploration  resulted  in  tearing  the  hepatic 
flexure  and  developing  a  large,  hard  mass  in  the  head  of  the  pancreas, 
which  was  supposed  to  be  malignant  and  apparently  completely  blocked 
the  pylorus.  The  gall  bladder  and  ducts  were  so  welded  into  the  mass 
as  to  be  unrecognizable.  The  problem  then  presented  was  what  to  do 
in  the  face  of:  1..  The  necessity  of  draining  the  abscess  cavity.  2.  The 
necessity  of  repairing  or  draining  the  torn  hepatic  flexure.  3.  The  ne- 
cessity of  relieving  the  obstructed  biliary  system.  4.  The  necessity 
of  relieving  the  obstructed  pylorus.  My  solution  of  the  problem  was 
eifected  in  this  way:  The  hepatic  flexure  was  completely  divided  and 
a  tube  tied  in  the  proximal  end  after  closing  the  distal  end.  The  abscess 
cavity  was  drained.  A  gastro-enterostomy  was  done.  The  gall  bladder  „  • 
would  also  have  been  drained  had  the  patient's  condition  permitted.  *J 
The  patient  rallied  from  operation  and  everything  went  well  until  10th  p  , 
day,  when  symptoms  resembling  lung  embolism  appeared.  After  being 
very  near  to  death  from  lung  complications,  there  seemed  some  hope  -p, 
of  recovery,  when  on  21st  day  new  abdominal  symptoms  appeared.  On 
23d  day  an  exploratory  operation  showed  the  abdominal  cavity  to  be  gj 
full  of  bile,  which  had  produced  very  little  peritoneal  reaction.  Drain- 
age was  instituted  because  the  patient's  condition  was  too  poor  to  p_j. 
admit  of  search  for  the  site  of  perforation  of  the  bile  passages. 
Result:  At  autopsy  this  proved  to  be  in  common  duct  just  above  mass 
felt  at  operation.  This  mass  had  greatly  diminished  in  size  and  on  sec- 
tion, instead  of  proving  to  be  malignant,  was  found  to  be  another  retro- 
peritoneal abscess  adjacent  to  the  head  of  the  pancreas  and  due  to  a 
perforation  of  the  common  duct  above  a  large  stone  in  the  ampulla. 
Further  careful  dissection  demonstrated  that  the  whole  condition  had 
been  due  to  this  retroperitoneal  perforation  of  the  common  duct.  This 
case,  together  with  cases  173  and  230  and  232,  illustrates  that,  as  far 
as  my  surgical  experience  goes,  it  is  often  impossible  to  tell  from  the 
feeling  of  a  mass  in  the  head  of  the  pancreas  whether  stone  or  malig- 
nant disease  is  present.  The  analysis  of  numerous  cases  must  decide 
the  question  as  to  whether  a  conservative  drainage  of  the  bile  or  ex- 
ploratory incision  in  the  mass  should  be  indicated  in  these  cases.  My 
own  opinion  is  that  more  cases  will  be  saved  by  incision  into  the  mass 
in  the  hope  of  finding  stone  or  pancreatitis. 


225.  Oct.  23,  1914.  Female — 43.  Acute  pelvic  inflammation.  (Neisser  in- 
fection?) Symptoms  characteristic  of  acute  pelvic  peritonitis.  No 
operation.  Douches  and  urotropin.  Symptoms  subsided  satisfactorily. 
Further  operation  advised  but  not  urged. 

Result:  Sept.   25,   1915— Well.     No  similar  attacks.     Sept.   11,   1916— 
Physician  reports  that  she  has  been  very  well  since  she  left  the  hospital. 


227.  Nov.  3,  1914.    Female— 63.    Under  care  of  Dr.  J.  W.  Seaver.    Pain  and 
stiffness  in  right  knee.    Hypertrophic  arthritis.    Massage  and  baking 
gave  relief  to  symptoms. 
Result:  Aug.  13,  1915 — "I  received  great  benefit." 


O  K 


226.  Oct.    28,    1914.     Female — 41.     Menorrhagia.     Large  fibroid  of  uterus. 
Op.  (E.  A.  C.) — Hysterectomy  and  appendectomy  (appendix  was  ob-    _ 
literated  and  adherent).    Comp. — None.  ^  ^ 

Result:  Aug.  21,  1916— Exam.— WeU.    Scar  solid. 


OK 


228.  Nov.  8,  1914.    Male — 52.    Subacromial  bursitis.    Calcification  in  supra- 

spinatus  tendon  beneath  the  base  of  the  subacromial   bursa.    Chronic    Q  K 
pain  for  a  year  and  very  acute  symptoms  for  the  last  7  weeks.    Op. 

41 


(E.  A.  C.) — Incision  and  removal  of  the  calcareous  mass.  Comp. — 
None. 

Result:  Aug.  25,  1915 — Still  slight  limitation  of  extreme  motions  and 
occasional  twinges  of  pain,  but  letter  expresses  great  satisfaction  with 
the  relief  experienced.  Sept.  13,  1916 — Letter — Well.  Trifling  limita- 
tion of  motion. 

229,  Nov.  13,  1914.  Male — 4.4.  Elephantiasis  nostras  of  both  legs.  Op.  (E. 
A.  C.) — Kondoleon  operation  on  both  sides  of  right  calf.  Comp. — 
None.  The  left  leg  was  not  operated  on  but  was  much  reduced  by  rest 
in  bed.  The  calf  of  one  operated  on  was  reduced  from  26  in.  to  15  in. 
Result:  Aug.  5,  1915 — The  gain  made  has  been  retained  by  the  use  of 
laced  canvas  stockings  covered  by  elastic  stockings.  Works  constantly 
on  feet.  Right  calf,  15  in.  Left  calf,  15^  in.  Gain  on  left  almost  as 
much  as  on  right.  This  case  was  seen  before  operation  by  many  of  the 
members  of  the  Clinical  Surgical  Association.     I  am  indebted  to  Dr. 

O  K  Matas  for  the  suggestion  of  the  Kondoleon  operation.    Aug.  14,  1916 — 

Letter — "I  have  been  able  to  work  every  day  since  I  started,  a  year 
ago  last  February.  My  legs  measure  round  the  calves :  the  right,  14 J  in. 
— the  one  that  was  operated  on;  and  the  left,  15  in.  You  will  see  that 
they  are  smaller  than  when  I  left  the  hospital.  I  continue  to  wear  the 
Corliss  stockings  and  the  rubber  over  them.  I  think  this  the  best  com- 
bination possible.  My  general  health  seems  to  be  very  good.  My  weight 
is  reduced,  so  that  I  feel  more  active,  and  my  flesh  is  now  healthy, 
and  not  of  the  water  look  that  I  had  before  the  operation.  I  continue 
to  sleep  with  my  feet  elevated  the  same  as  when  I  was  in  the  hospital, 
and  I  cannot  rest  well  in  any  other  position,  I  am  so  used  to  it." 

230.  Nov.  2T,  1914.  Male— 59.  Under  the  charge  of  Dr.  H.  F.  Vickery. 
Diabetes  mellitus  and  suspected  cancer  of  pancreas.  Deep,  obstructive 
jaundice;  intense  itching;  loss  of  weight  and  appetite  for  1  year. 
Treated  by  dietetic  measures  which  resulted  in  great  diminution  of 
sugar.  Re-entry  Dec.  25,  1914.  Op.  (E.  A.  C) — Under  diagnosis  (1) 
of  cancer  of  duodenal  papilla,  (2)  cancer  of  head  of  pancreas,  or 
(3)  stone  in  ampulla.  The  gall  bladder  was  found  to  be  distended 
and  the  common  duct  obstructed  by  a  hard  tumor  in  the  head  of  the 
pancreas  about  the  size  of  a  horse  chestnut.  As  it  was  impossible  to 
rule  out  stone  by  feeling  alone,  an  incision  was  made  into  the  duodenum 
and  an  effort  made  to  probe  the  duct.  As  this  was  unsuccessful,  an 
incision  was  made  directly  into  the  tumor  through  the  posterior  wall 
of  the  duodenum.    Evidently  the  pancreatico-duodenalis  artery  was  cut, 

p_j  for  a  severe  hemorrhage  occurred  which  could  only  be  controlled  by 

packing.    As  it  was  obviously  impossible  to  leave  the  packing  in  situ, 

E.j  it  was  felt  that  tne  only  hope  of  success  lay  in  the  radical  operation 

of  removing  the  entire  head  of  the  pancreas,  for  if  the  diabetes  were 

E-d?  <5"^  to  t'l^  obstruction  in  this  organ,  there  might  be  a  chance  of  re- 

covery after  its  removal.  Accordingly  the  second  portion  of  the  duo- 
denum and  head  of  the  pancreas  were  removed  en  masse.  The  distal 
end  of  duodenum  was  sewed  over  the  stump  of  tail  of  pancreas  in  the 
manner  recommended  by  Coffey.  The  proximal  end  was  anastomosed 
to  a  coil  of  jejunum  and  a  cholecystenterostomy  also  made  with  the 
same  coil.  The  abdominal  wound  was  closed  except  for  a  small  drain. 
After  the  operation  he  had  no  vomiting,  distention,  abdominal  pain,  or 
other  untoward  symptom,  except  on  the  2d  day  coma  of  gradually 
increasing  intensity. 

Result:  Death  on  the  5th  day.  After  death  I  examined  the  wound  and 
found  it  clean  and  sound — even  tlie  cut  end  of  the  pancreas  having  no 
slough  or  pus.  Both  anastomoses  of  the  intestine  were  healing  nicely. 
There  was  no  dilatation  of  the  stomadi,  and  tlie  anastomosis  made  by 
the  l)utton  was  in  good  condition.  During  the  Ave  days  after  operation 
less  than  ten  ounces  of  urine  were  passed.  This  case  shows  that  excision 

42 


of  the  head  of  the  pancreas  is  anatomically  and  surgically  possible.  In 
other  words,  this  case  has  taught  me  that,  given  a  small  cancer  of  the 
head  of  the  pancreas  in  a  patient  without  diabetes,  it  would  be  justi- 
fiable to  deliberately  plan  to  remove  the  disease.  Path,  report  of  the 
specimen  by  Dr.  J.  H.  Wright  shows  diffuse  chronic  pancreatitis  with 
almost  complete  destruction  of  the  pancreatic  tissue.  Ingrafted  on  this 
was  a  carcinoma. 

231.  Dec.  27,  1914.     Female — 53.     Abdominal   tumor  size  6  months  foetus. 
Ascites.     Pre-op.    diag. — Ruptured    papillomatous    ovarian    cyst.     Op. 

(E.   A.  C.  and  A.  W.  Reggio) — General  panillomatous  implantations    p_^ 
scattered  over  whole  peritoneum.    A  mass  still  recognizable  as  a  rup- 
tured cyst  was  with  difficulty  removed,  leaving  a  raw  surface  of  evi-    p_j. 
dent  malignant  tissue.    A  cigarette  drain  was  carried  to  this  point  and 
the  wound  closed.    Comp. — None,  but  at  the  time  of  discharge,  three 
weeks  after  operation,  palpable  masses  were  evident. 
Result:  Died  at  her  home,  Feb.  21,  1915. 

232.  Jan.   5,   1915.     Male — 38.     Painless  jaundice   of   two   years'    duration. 
Ascites,  oedema  of  the  legs,  etc.    No  stomach  symptoms.    Pre-op.  diag. 
- — Obstructive  jaundice  from  (1)  ulcer  at  papilla,  (2)  chronic  pancrea- 
titis,  (3)  stone  in  the  common  duct.     Op.   (E.  A.  C.  and  Dr.  W.  W. 
Harvey)— About   two    quarts   of   bile-stained   ascitic   fluid   evacuated. 
Gall  bladder  was  found  to  be  greatly  dilated  and  a  small  hard  tumor 
was  present  in  the  head  of  the  pancreas.    A  nodule  the  size  of  a  pea 
was  noticed  in  the  edge  of  the  left  lobe  of  the  liver  and  was  supposed 
to  be  a  cyst.    It  was  impossible  for  me  to  tell  the  nature  of  the  tumor 
except  by  incision,  as  in  case  230.    It  seemed  probably  inflammatory,    „   - 
either  due  to  chronic  pancreatitis  or  a  posterior  duodenal  ulcer.  There- 
fore it  seemed  as  if  the  patient  had  a  chance  of  relief  from  simple    p,  • 
drainage  of  the  gall  bladder,  since  this  has  been  shown  to  be  of  value       "^ 
in  chronic  pancreatitis.    This  was  accordingly  done,  with  the  intention    g_ 
of  doing  a  secondary  radical  operation  if  the  jaundice  disappeared  and 

the  sinus  did  not  close.  Comp. — None,  except  blood  clot  in  wound 
without  temperature  or  pain.  Re-entry,  Apr.  11,  1915.  Sinus  had  not 
closed.  Ascites  had  returned.  General  condition  was  worse.  Op.  (E. 
A.  C.  and  Dr.  W.  W.  Harvey) — The  small  nodule  in  the  liver  had 
grown  to  the  size  of  a  horse  chestnut.  Other  nodules  had  appeared 
and  the  pancreatic  tumor  had  greatly  increased  in  size.  Nothing  could 
be  done.  Comp. — None.  Returned  to  his  home  in  N.  S.  on  the  5th  day 
after  the  operation. 
Result:  Died  May  3,  1915, 

233.  Jan.  16,  1915.  Female — 46.  Congenital  malformation  of  spine  result- 
ing in  wry  neck,  cervical  rib,  lumbo-sacral  strain,  lumbo-sacral  anoma- 
lies, and  nerve  root  pains  in  cervical  and  sciatic  plexuses.  Had  previ- 
ously had  appendix  removed  and  ventral  fixation  by  another  surgeon. 
No  treatment  was  given  this  patient,  but  the  searching  examination  re- 
sulting in  a  definite  diagnosis  will  enable  her  hereafter  to  modify  her  Q  K 
life  to  the  conditions  nature  has  imposed  upon  her,  instead  of  spending 

time  and  money  in  a  futile  search  for  a  cure.  Her  symptoms  can  be 
relieved,  but  the  cause  of  the  symptoms  will  be  permanent  and  must 
be  allowed  for. 

Result:  Aug.  17,  1915 — Letter — Better.  Happier.  Aug.  18,  1916 — 
Letter — Much  improved. 

234.  Jan.   19,  1915.    Female — 41.    A  large  and  stout  patient,  with  nervous 
and  abdominal  symptoms  associated  with  the  menstrual  period.    Retro- 
version of  uterus.     Op.   (E.  A.  C.) — Ventral  fixation.     Removal  of  a    E-c 
stenosed    kinked    appendix    containing    a    concretion.     Very    movable 
cecum  and  an  hourglass   gall  bladder  were  also  noted,   but  were  not 

48 


altered.    Comp. — None,  except  a  tiny  spot  where  skin  apposition  was 

defective. 

Renvlt:   Sept.   2,   1916 — Exam. — Scar   solid.    Uterus   in   good    position. 

A  most  satisfactory  result  in  the  relief  of  menstrual  symptoms.    Still 

complains  of  some  indigestion.  July  4,  1916 — Physician  writes,  "I  tliink 

she  was  much  benefited  by  your  treatment." 

235.  Jan.  27,  1915.  Female — 33.  Chronic  pain  and  soreness  in  pelvis  and 
right  iliac  fossa,  following  operation  eight  years  ago  by  another 
surgeon.  Pre-op.  diag. — Adhesions  of  cecum  to  abdominal  scar.  Op. 
(E.  A.  C.  and  R.  F.  Sheldon) — Old  scar  removed  and  multiple  adhe- 
sions of  small  intestine  separated  and  raw  surfaces  covered  by  peri- 

„  toneal  plastics.  The  appendix,  which  was  also  involved  in  the  adhesions, 

was  removed.  There  were  many  other  adhesions  which  could  not  be 
removed,  but  the  whole  abdominal  condition  was  apparently  greatly 
improved.  Comp. — None,  except  small  spot  at  angle  of  wound  pulled 
apart  by  adherent  gauze. 

Result:  Aug.  19,  1915 — Looks  perfectly  well.  Scar  solid.  Still  com- 
plains of  similar  symptoms.  Aug.  21,  1916 — Exam. — WeU.  Scar  solid. 
Minor  complaints. 

236.  Jan.  27,  1915.  Female — 32.  Left-sided  abdominal  pain  for  2  weeks 
and  for  several  years  pain  of  some  kind.  Pelvic  lacerations.  Left- 
sided  abdominal  tumor.  Pre-op.  diag. — Partial  volvulus  of  left  tube, 
with   pressure  on  left  ureter.     Op.    (E.  A.  C.  and   A.  W.   Reggio) — 

•p  J  Tumor  proved  to  be  an  encapsulated  extra-uterine  pregnancy  limited 

by  an  adherent  sigmoid  flexure.     Left  tube  and  ovary   with  clot  and 
foetus  removed.    Drainage  of  oozing  cavity.    Comp. — None. 
Result:  Aug.  23,  1915 — Looks  very   well.    Slight  complaint  of  leucor- 
rhoea  and  pelvic  discomfort.     Not  exam.     Aug.  6,  1916 — Well.     Occa- 
sional "pain  in  side." 

237.  Feb.  3,  1914.  Female — 45..  Acute  abdominal  pain  and  pelvic  tumor 
size  child's  head.  Three  months  previously  a  rectal  hemorrhage.  Pre-op. 
diag. — Ovarian  cyst  with  twisted  pedicle.  Op.  (E.  A.  C.  and  A.  W. 
Reggio) — Tumor  proved  to  be  ovarian  and  was  cystic  because  necrotic 
in  the  center.  After  its  removal  the  rectum  was  examined  to  find  any 
possible  cause  for  the  previous  hemorrhage.  At  the  rectosigmoidal 
junction  was  apparently  a  tight  stricture  evidently  malignant.  Above 
this  in  the  sigmoid  was  a  pedunculated  intra-intestinal  tumor  the  size 
of  a  horse  chestnut,  as  well  as  several  smaller  masses.  The  right  ovary 
was  also  enlarged  to  the  size  of  a  small  lemon.  There  were  at  least 
two  metatases  in  the  liver.  Since  the  patient's  strength  was  fairly  good 
and  she  had  shown  little  cachexia  in  spite  of  the  extensive  character 

E-d  of  the  disease,  we  decided  to  excise  the  upper  part  of  the  rectum  and 

sigmoid  instead  of  making  an  artificial  anus.    End  to  end  anastomosis 

P-d  was  completed  with  a  Harrington  ring.    The  handle  of  this  instrument 

made  possible  an  otherwise  very  difficult  suture  in  the  depths  of  the 
pelvis.  Drainage  of  the  superficial  portion  of  wound.  Comp. — None. 
The  specimens  were  examined  by  Dr.  Mallory,  who  reported  that  the 
primary  condition  was  benign  adenomata  of  the  mucosa  of  the  sigmoid. 
One  tumor  had  become  malignant,  ulcerated,  and  formed  metastases 
in  the  liver  and  ovary.  On  June  17,  1915,  the  patient,  who  had  been 
comfortable  until  within  a  few  weeks,  re-entered  with  similar  symp- 
toms, especially  abdominal  distention  and  a  tumor  on  the  right  side 
of  the  abdomen.  At  this  time  there  was  profound  cachexia  and  severe 
pain.  In  spite  of  the  palpable  liver  metastases,  it  seemed  best  to  try 
to  remove  the  (probably)  ovarian  tumor  which  was  pressing  on  the 
rectum.  Op.  June  18  (E.  A.  C.  and  A.  R.  Barrow)— A  tumor  similar 
to  the  previous  one  was  removed  with  difficulty,  as  it  was  densely  ad- 
herent to  the  pelvic  and  abdominal  organs.    It  was  necrotic  and  friable 

44 


and  much  of  it  was  scooped  out.  Small  parts  of  it  were  unavoidably 
left  in  the  ragged  wound.  Other  small  metastases  were  present  in  the 
omentum  and  fat.  A  drain  was  left  in  the  bleeding  cavity,  and  the 
abdominal  wall  closed.  In  spite  of  her  cachectic  condition,  the  conva- 
lescence was  comfortable  except  for  the  parting  of  the  skin  incision 
from  distention.  Pain  was  relieved  and  she  was  able  to  get  up.  July  30, 
1915 — Relieved  of  pain,  but  weak.  Still  able  to  sit  up. 
Result:  Died  at  home,  Aug.  29,  1915. 

238.  Feb.   8,    1915.     Male — 26.     Subcoracoid   dislocation   of   right   shoulder, 
which  had   been  recently  reduced  by  another  surgeon  and  had  again 
recurred.    It  was  easily  reduced  without  ether.  O  K 
Result:  July  2,  1915 — Letter — Recurrence  took  place  again  within  a  few 
weeks,  but  was  easily  reduced  again  by  local  physician. 

239.  Feb.  13,  1915.  Male — 52.  Subacromial  bursitis  due  to  calcification  in 
supraspinatus  tendon.  Op.  (E.  A.  C.  and  R.  F.  Sheldon) — Incision 
of  bursa  and  removal  of  calcareous  mass.    Comp. — None. 

Result:  Aug.  26,  1915 — Phys.  reports,  "Good  result,  but  patient  still  has 
slight  limitations  in  extreme  motions."  Aug.  16,  1916 — Letter — "I  have 
not  been  bothered  much  with  my  shoulder.  The  only  difficulty  is  in  ^  •'^ 
getting  on  my  coat,  but  I  find  a  great  improvement  in  that  within  a 
month.  I  did  the  exercising  that  you  suggested  up  to  a  few  weeks  ago, 
when  I  discontinued  and  substituted  using  the  arm  in  swimming  and 
playing  baU.  I  find  that  has  helped  me  considerably.  My  general  health 
is  good." 

240.  Feb.  15,  1915.    Male— 10.    Acute  appendicitis   (17  hours).    Op.   (E.  A. 

C.  and  A.  N.  Reggio) — Appendectomy  and  removal  of  small  portion    q  j^ 
of  omentum  which  was  wrapped  about  an  inflamed  appendix  contain- 
ing a  large  concretion.    Comp. — None. 
Result:  Oct.  16,  1916— Exam. — Well.    Scar  normal. 

241.  Feb.   16,  1915.    Male — 52.    Pain  in  right  inguinal  region.    This  patient 
had  been  previously  operated  on  for  the  same  symptoms  by  the  follow- 
ing distinguished  surgeons:  Dr.  S.  J.  Mixter,'Dr.  J.  G.  Mumford,  Dr. 
H.  O.  Marcy,  Dr.  M.  H.  Richardson,  Dr.  C.  A.  Porter.    The  patient 
was  wearing  a  truss,  although  no  hernia  existed.    It  seemed  to  me  that    g_g 
a  nerve  bulb  in  the  scar  was  probably  the  cause  of  his  pain.    Under 
novocaine  careful  dissection  of  the  dense  scar  tissue  revealed  a  nerve    •£_(• 
bulb  which  seemed  likely  to  be  the  cause  of  the  symptoms.    Comp. — 
None,  except  haematoma  in  the  wound,  which  healed  without  suppura-   p_d 
tion. 

Result:  July  1,  1915 — Recently  this  patient  has  reported  that  the  pain 
is  as  bad  as  before.  No  hernia  is  demonstrable.  Aug.  12,  1916 — Letter 
— "I  am  feeling  fairly  well,  but  at  times  the  pain  from  the  cut  nerve 
is  almost  unbearable.  As  a  result,  I  am  unable  to  tackle  anything 
requiring  strength." 

242.  Feb.   24,    1915.     Female — 33.     Very   large   abdominal   tumor.     Pre-op. 
diag.   by   E.   A.  C. — Ovarian  cyst.     By  Dr.  Koch — Fibroid   of  uterus. 

Op.  (E.  A.  C.  and  Dr.  F.  L.  Koch) — Hysterectomy  and  appendectomy.    E-d 
Appendix  adherent  but  not  strictured.    Comp. — None. 
Result:  Sept.  1,  1916 — Physician  reports,  "Patient  well." 

243.  Mar.    1,    1915.     Female — 7.     Subacute    abdominal    pain    for    10    days. 
"Cake"  in  right  iliac  region  for  24  hours.  Local  tenderness.  Temp.  101. 
Pre-op.  diag. — Acute  appendicitis.    Op.  (E.  A.  C.  and  A.  W.  Reggio)  — 
"Cake"  proved  to  be  a  mass  of  tuberculous  mesenteric  glands.    Evi-    g.^ 
dently  due  to  a  localized  tuberculous  area  in  ileum  near  valve,  about 

1^  by  1  in.  in  length.  This  area  was  indurated  and  felt  as  if  ulcerated 
on  inner  side.  Appendix  was  normal — not  removed  for  fear  that  the 
trauma  might  stir  up  the  tuberculosis.    Comp. — None. 

45 


O  K 


Resiilt:  Aug.  16,  1915 — Exam. — Well.  One  small  movable  gland  pal- 
pable at  site  of  former  "cake."  Aug.  1,  1916 — Father  reports  to  physi- 
cian that  patient  is  well. 

244.  Mar.  14,  1915.  Female — 28.  Tender  tumor  to  right  of  spine  at  junc- 
tion of  12th  rib.  Pre-op.  diag. — Angioma?  dermoid  cyst?  lipoma? 
fibroma?  sarcoma?  wen?  cold  abscess?  Op.  (E.  A.  C.) — Tumor 
proved  to  be  a  small  cold  abscess  between  the  fascia  and  muscle  of  the 

E-d  erector  spinas.     It  was  removed  entire.     On  section  found  to  contain 

thick  pus  with  a  few  spicules  of  bone.    (Pure  staph,  aureous.)    Wound 

E-c  closed  tight.    Comp. — None,  except  collection  of  serum  which  was  evac- 

uated on  a  director  several  times. 

Result:  Aug.  10,  1915 — Letter — At  times  her  back  troubles  her,  and 
the  wound  is  tender,  burns,  twinges,  and  aches.  Aug.  8,  1916 — Letter — 
WeU. 

246.  Mar.  29,  1915.    Male — 47.    Irregular  ulcerated  perineal  scar  following 
dissection  of  a  very  extensive  tuberculous  fistula  with  sinuses  in  ischio- 
rectal fossa  and  buttocks,  in  Aug.,  1914,  by  E.  A.  C.     Op.   (E.  A.  a 
O  K  ^"^  ^-  ■^-  Sheldon) — Excision  of  sinus  and  division  of  sphincter.  Comp. 

— None. 

22esM«;  July  26,  1916— Well.  Slight  cough.  July  31,  1916— Well.  Scar 
normal.  Recent  examination  of  the  lungs  by  Dr.  John  B.  Hawes 
negative. 

246.  Apr.  6,  1915.  Male — 12.  Pneumonia  3  weeks  ago.  Classical  signs  of 
empyema.  Op.  (E.  A.  C.) — Portion  of  10th  rib  excised,  drainage  by 
E.  A.  C.'s  modification  of  A.  T.  Cabot's  method,  no  air  being  allowed  to 
enter  thorax.  Comp. — None.  Healed  in  3  weeks,  except  for  small  spot 
of  granulation. 

Result:  Aug.  19,  1916 — Physician  writes:  "In  perfect  health.  He  does 
not  cough,  has  no  deformity,  and  operative  scar  is  very  slight.  There 
is  some  evidence  of  slight  pleural  thickening." 

247.  Apr.  15,  1915.  Male — 48?  Violent  left-sided  abdominal  pain  for 
24  hours.  Pyrexia,  vomiting,  prostration,  leucocytosis.  Neg.  X-ray. 
Patient  was  kept  for  5  days  under  observation  under  the  diagnosis  of 
hsematogenous  infection  of  the  kidney.  As  his  condition  grew  worse 
it  was  felt  that  perinephritic  abscess  was  present.  Op.  (E.  A.  C.  and 
A.  W.  Reggio) — Kidney  was  found  adherent  to  fatty  capsule,  but 
showed  no  abscesses  on  its  surface.  It  was  large  and  congested  look- 
ing, and  it  did  not  seem  sufficiently  pathologic  to  account  for  the  pain, 
so  the  peritoneal  cavity  was  explored  with  negative  results.  Gall 
bladder  felt  normal.  Nothing  satisfactory  seemed  to  have  been  accom- 
plished, but  on  recovering  from  ether  the  patient  alleged  that  he  was 
relieved  of  the  pain  from  which  he  had  previously  suflfered !  Comp. — 
None,  except  on  the  6th  and  6th  days  many  normal  and  abnormal  blood 
corpuscles  appeared  in  the  urine.  Was  the  relief  caused  by  this  opera- 
tion due  to  the  dislodgment  of  a  minute  stone  or  by  separation  of  the 
perirenal  adhesions? 

Result:  Aug.  12,  1916 — Physician  writes:  "Has  steadily  gained  in 
wei"-ht  and  is  feeling  well  and  strong,  except  that  he  has  dizzy  speUs 
lasting  for  a  short  time,  a  few  minutes,  two  or  three  times  a  week. 
His  appetite  is  good  and  he  has  no  pain  in  the  region  of  the  operation. 
Urine  is  normal.  Thinks  he  is  getting  too  stout  now,  and  is  trying  to 
keep  in  good  condition  by  plenty  of  walking.  No  similar  attack  since 
operation." 

248.  Apr.  16,  1915.  Female — 23.  Entered  with  the  characteristic  symptoms 
of  pelvic  peritonitis  from  acute  tubal  infection.    Vaginal  exam,  showed 

g_g  a  large  mass  in  the  posterior  cul-de-sac  considered  to  be  a  tube  dis- 

tended with  pus.  Patient  was  kept  under  observation  for  12  days,  when 
all  symptoms  had  disappeared  except  a  slight  induration  of  the  post. 

46 


E-d 


cul-de-sac.  Op.  (E.  A.  C.  and  R.  H.  Miller) — Both  tubes  slightly 
swollen  and  reddened.  Left,  which  was  adherent  with  recent  fibrin, 
was  removed.  Appendix  containing  concretions  was  removed.  Comp. — 
None,  except  slight  serous  discharge  from  wound  for  2  days.  Path, 
exam,  showed  that  the  tube  was  normal,  with  exudate  on  the  outside. 
Result:  Aug.  2,  1916— Letter— Well. 

249.  Apr.  16,  1915.    Male — 75.    Acute  distention  of  the  gall  bladder.    Chole- 
lithiasis and  cholecystitis.  Op.  (E.  A.  C.) — Cholecystostomy.  One  large 
gallstone  removed.    Comp. — None.  O  K 
Result:  Aug.  2,  1916 — Physician  reports  that  patient  is  suffering  from 
furunculosis,  but  generally  is  well  and  strong  as  ever,  and  able  to  do 

his  full  day's  work. 

250.  Apr.  17,  1915.  Female — 35.  Periodic  attacks  of  abdominal  pain  and 
vomiting.  Chronic  tonsillitis.  Fissura  ani.  Small  hemorrhoids.  Neuras- 
thenia (?).  Cystic  cervix.  Two  previous  abdominal  operations.  Op. 
(E.  A.  C.) — Sphincter  stretched  and  hemorrhoids  cauterized.  Comp. — 
None.  May  13,  1915 — Both  tonsils  removed  by  Dr.  J.  L.  Goodale. 
Re-entry  July  18,  1915 — Same  symptoms.  Op.  (E.  A.  C.  and  A.  R.  B.) 
— Adhesions  at  old  scar  separated.  A  band  representing  old  suspension 
operation  was  removed.  The  sigmoid  had  evidently  been  getting  caught 
about  this  band,  for  two  appendices  epiploicse  had  twisted  together,  E-s 
and  one  had  become  gangrenous.  Uterus  again  suspended  by  shortening 
round  ligaments.  Re-entry  Jan.  16,  1916 — Attack  vomiting,  etc.,  wliich 
soon  subsided.  Re-entry  June  13,  1916 — Attack  vomiting  and  diarrhoea. 
Soon  subsided. 

Result:  Aug.  2,  1916 — Letter — "I  am  feeling  generally  better  and  much 
stronger,  and  do  not  tire  as  easily."  Still  has  various  minor  complaints. 
Apr.  4,  1917 — Attack  of  bacteriuria.  Cystoscopy  negative.  Urine 
cleared  up  under  urotropin.  • 

251.  Apr.  18,  1916.    Female — 34.    Tumor  at  left  angle  of  jaw  size  of  horse- 
chestnut.    Pre-op.  diag.^ — Tuberculous  gland.    Op.  (E.  A.  C.  and  A.  W. 
Reggio) — Tumor  proved  to  be  an  enchondroma  of  parotid.    Excised.    E-d 
Comp. — None. 

Result:  Aug.  14,  1916 — Exam. — No  symptoms.  Scar  is  hardly  noticeable. 

262.  Apr.  19,  1915.  Male — 58.  Persistent  ulceration  and  tumor  post,  por- 
tion of  left  lower  jaw.  Two  operations  had  previously  been  done  by 
another  surgeon.  Pre-op.  diag.  from  excised  specimen — Adamantinoma. 
Op.  (E.  A.  C.  and  Dr.  M.  L.  S.  Miner) — Excision  of  posterior  half  of 
left  lower  jaw.  As  tumor  extended  beyond  upper  jaw  this  operation  pj.gp 
had  to  be  very  radical.  There  was  excessive  hemorrhage,  controlled  by 
packing.  Comp. — Pulmonary  embolism,  phlebitis.  Long  convalescence. 
Healed  in  7^  weeks. 

Result:  July,  1915 — Well.  An  excellent  cosmetic  result.  Can  open 
mouth  and  appose  teeth.    Feb.  8,  1917 — Physician  reports,  "Well." 

253.  Apr.  29,  1915.  Female — 33.  Uretero-vaginal  fistula  following  hyster- 
ectomy for  cancer  by  another  surgeon  1  year  previously.  Albuminuria. 
Pyuria.  By  the  red  test  the  urine  from  the  vaginal  fistula,  left  ureter, 
was  found  to  be  i%,  and  on  the  right  to  be  40%.  Consultation  with 
Dr.  J.  D.  Barney.  Op.  (E.  A.  C.  and  J.  D.  B.)— The  left  kidney  and 
dilated  left  ureter  removed  to  vaginal  scar;  specimen  showed  that  P-d 
kidney  substance  had  practically  disappeared.  Pelvis  and  ureter  full 
of  foul  pus.  Comp. — None.  This  case  is  a  good  illustration  of  the 
observation  of  E.  A.  C.  {Boston  Med.  and  Surg.  Journ.,  Aug.  5,  1909) 
that  stricture  of  the  distal  end  of  the  ureter  produces  dilatation  of  the 
ureter  instead  of  the  renal  pelvis.  It  is  also  illustrative  of  the  prin- 
ciples laid  down  by  Dr.  Barney  in  his  research  on  the  results  of  ligation 

47 


of  the  ureter    {Surgery,  Gynecology,  and  Obstetrics,  Sept.,  1912,  pp. 

290-295). 

Result:   Aug.    1,    1915 — Letter — "Almost   well.     Some    pain    in   back." 

Aug.   16,   1916— Exam. — Well.     Scar  solid.     Urine  clear.     Referred  to 

Peter  Bent  Brigham  Hospital  for  epileptiform  seizures  which  she  has 

had  occasionally  for  some  years. 

254.  May  3,  1915.  Male — 23.  Several  previous  attacks  of  typical  appendicial 
symptoms,  the  last  2  weeks  before  entrance,  when  he  had  been  under 

O  K  observation  of  competent  physician.    Op.  (E.  A.  C.  and  R.  F.  Sheldon) 

Novocaine  anaesthesia.  Appendectomy.  Appendix  showed  no  indica- 
tion of  recent  or  old  inflammation.    Comp. — None. 

Result:  Aug.  2,  1916 — Exam. — Scar  solid.  No  abdominal  symptoms. 
WeU. 

255.  May  4,  1915.  Female — 64.  Chronic  dyspepsia  of  many  years'  standing. 
Recently  loss  of  weight  and  appetite.  Gastric  retention  of  over  48 
hours    demonstrated    by    X-ray.     Attacks    of   diarrhoea.     Prolapse    of 

g__  uterus.    Condition  feeble.    Op.    (E.  A.  C.  and  G.  W.  M.) — There  was 

a  small,  hard,  irregular  mass  at  the  pylorus.    It  seemed  more  like  ulcer 
■tp-  than  cancer.    Post,  gastroenterostomy.    Comp. — Vomited  small  amounts 

of  blood   in  first   24   hours.    Liquid  blood   clot   twice   evacuated  from 

wound.    No  suppuration. 

Result:   Nov.   28,   1916 — Exam. — Well.    Has  gained  too   much  weight. 

No  digestive  symptoms.  A  small,  symptomless  hernia  in  middle  of  scar. 

Recently  fractured  greater  tuberosity  of  left  humerus. 

256.  May  8,  1915.  Female — 25.  Two  previous  attacks  of  appendicial  symp- 
toms; pain  and  tenderness  for  48  hours.  Pre-op.  diag. — 1.  Chronic  sal- 
pingitis. 2.  Subacute  appendicitis.  Op.  (E.  A.  C.  and  R.  H.  Miller) 
— Appendectomy.  Term,  half  of  appendix  was  obliterated  and  prox. 
half  was  distended  with  turbid  fluid.  Tubes  and  ovaries  normal.  A 
small  fibroid  in  uterus  was  not  disturbed.    Comp. — None. 

Result:  July  30,  1915— Well.  Flat  foot.  Hallux  valgus.  Aug.  22,  1916 
— Exam. — Scar  deeply  pigmented.  Has  recently  been  through  a  normal 
confinement.    Well.    Small  fibroid  in  uterus  not  palpable. 

257.  May  13,  1915.  Female — 40.  Tumor  of  upper  half  of  humerus  size  of 
grape  fruit.  Pre-op.  diag. — Osteochondroma.  Op.  (E.  A.  C.  and  T.  W. 
Harmer) — Growth  was  removed  piecemeal  until  all  the  important 
nerves  and  other  structures  imbedded  in  it  were  isolated.  About  4  in. 
of  the  bone  from  which  it  sprang  was  removed,  leaving  the  articular 
head.  Crumbs  of  tumor  were  unavoidably  entangled  in  the  large 
wound.  Plastic  repair  of  muscles.  Comp. — None.  Diagnosis  confirmed 
by  path,  report  by  Dr.  Mallory.  Not  malignant.  At  time  of  discharge 
this  patient  could  move  all  the  muscles  and  there  was  no  sign  of  motor 

OK  ^^  sensory  nerve  injury. 

Result:  Aug.  27,  1915 — Exam. — In  good  health.  No  sign  of  recurrence. 
Good  use  of  hand.  Strong  pull  but  no  abduction.  Can  use  fork.  Can 
do  hair  by  stooping.  Sept.  15,  1916 — Re-entry.  Several  small  local  re- 
currences not  interfering  with  function — removed.  Nov.  13,  1916 — 
Re-entry.  Remaining  bone  of  upper  end  of  humerus  excised  with 
growth  about  size  of  fist.  Upper  end  of  lower  fragment  also  excised. 
Comp. — Slight  parting  of  skin  edge  for  half  an  inch.  Two  weeks  after 
operation  able  to  use  hand  and  forearm.  No  sign  of  malignancy. 
Mar.  31,  1917 — Letter  saying  she  is  able  to  use  arm  pretty  well,  but 
not  as  well  as  before  the  last  operation. 

268.  May   18,   1915.     Male — 59.     Progressive   loss  of  weight   for  3  months. 
_   ,  Recurrent   attacks   of   abdominal   cramps.    Abdominal    distention    and 

^"^  visible    peristalsis.    Severe    pain.    Pre-op.    diag. — Acute    intestinal    ob- 

struction from  cancer  of  recto-sigmoidal  junction.    Op.   (E.  A.  C.  and 

48 


E-d 


G.  W.  M.) — Besides  many  small  metastases  there  were  two  large  masses 
of  cancer,  one  at  the  ileo-cecal  region  and  one  at  the  recto-sigmoidal 
junction.  It  could  not  be  determined  which  was  primary,  but  the  acute 
obstruction  was  evidently  caused  by  the  ileo-cecal  tumor,  for  coils  of 
small  intestine  were  enormously  distended.  These  coils  were  very  satis- 
factorily evacuated  on  a  Monks'  tube  and  a  lateral  anastomosis  made 
between  the  transverse  colon  and  the  ileum  at  the  point  incised  for  the 
Monks'  tube.  Wound  closed  without  drainage.  Comp. — None. 
Result:  July  29,  1915 — Letter — Slight  gain  in  strength.  Able  to  attend 
to  business  part  of  the  week.   Died  of  same  disease  Nov.  10,  1915. 

259.  May  27,  1915.  Female — 54.  Intermittent  periods  of  disability  owing 
to  locking  of  left  knee  and  consequent  synovitis.  X-ray  showed  pecul- 
iar round  bodies  under  supra-patella  tendon.  Op.  (E.  A.  C.  and  A.  R. 
Barrow) — Removal  of  mass  of  fatty  synovial  tissue  on  which  calcified 
beads  were  hung  by  short  pedicles — evidently  calcified  lipoma  arbores-  O  K 
cens.    Comp. — None.    About  30°   of  motion  and  some  effusion  at  time 

of  discharge,  3  weeks  after  operation.    Could  walk  with  slight  limp. 
Result:  Aug.  14,  1915 — Still  somewhat  stiff  and  has  some  difficulty  in 
walking  downstairs.    May  22,  1916 — Husband  reports,  "Well." 

260.  June   1,   1915.     Female — 31.     Under   the  care   of   Dr.   W.   P.   Graves. 
Dysmenorrhoea.    Op.  (W.  P.  G.) — Dilatation  and  curettage.    Comp. —   q  jr 
None. 

Result:  Aug.  15,  1915 — ^"Only  fairly  satisfactory  so  far." 

261.  June  2,  1915.  Male— 63.  Cancer  of  lip.  Op.  (E.  A.  C.  and  A.  R.  B.)— 
V-shaped  resection  under  novocaine.  Comp. — None.  Re-entry  June  21, 
1915,  on  account  of  palpable  glands  in  submental  region.  Under  novo-  jj_q 
caine  these  were  removed  with  the  adjacent  tissue,  but  on  microscopic 
section  showed  no  cancer  cells.  Comp. — Collection  of  sero-sanguinous 
fluid  in  wound. 

Result:  July  25,  1916— Well. 

262.  June  14,  1915.  Female — 55.  Deformed  great  toenail.  Op.  novocaine 
(E.  A.  C.  and  A.  R.  B.) — Excision  of  matrix  and  a  portion  of  phalanx, 
Comp. — None. 

Result:  Feb.  19,  1916 — Re-entered  for  cardiac  condition  following  an    O  K 
attack  of  grippe.    Blood  pressure  200.    Dr.  George  C.  Shattuck  in  con- 
sultation.   Diagnosis   of  arterio-sclerosis.    Toe  O.  K.    Scar   rough   and 
hard. 

263.  June   14,    1915.    Female — 76.    Fracture   of   external  malleolus  without 
displacement.    Comp. — None.  q  jr 
Result:  Aug.  9,  1916 — Letter — "I  have  never  really  had  any  bad  effects 
from  my  broken  leg." 

264.  June    20,    1915.     Female — 59.    Diabetes    mellitus.    Diabetic    neuritis. 
Threatening  gangrene  of   foot.     Under   the   charge   of  Dr.  John  W. 
Dewis.    Anti-diabetic  diet.    Symptoms  subsided  to  a  great  extent. 
Result:  May  25,  1916 — Re-entered.    Ingrowing  toenail  which  threatens    ^  -j^ 
to  cause  ulceration  of  toe.    Conservative  treatment  successful  without 
operation.    Developed  herpes  zoster  while  in  hospital.    Aug.  2,  1916 — 

'  Letter — "No  more  trouble  with  the  toenail.    The  toe  and  a  portion  of 
the  foot  are  still  troublesome." 

265.  June  22,  1915.  Female — 48.  Pain  in  distribution  of  right  ant.  crural 
nerve.  Uterine  fibroids  pressing  on  lumbar  plexus.  Op.  (E.  A.  C.  and 
A.  R.  B.) — Hysterectomy.  Comp. — Serous  discharge  from  wound, 
which  healed  promptly.  E-c 
Result:  Dec.  13,  1916 — Still  complains  of  pain  in  back  of  neck  and 
undue  fatigue  after  exertion.  Exam. — Scar  O.  K.  Cervix  in  good  posi- 
tion.   Has  gained  20  lbs.,  but  even  now  weighs  only  110. 

49 


266.  June  22,  1915.  Female — 44.  Profuse  menorrha<Tla.  Large  uterine 
fibroid.    Op.  (E.  A.  C.  and  A.  R.  B.) — Hysterectomy.    Appendectomy. 

g._p  Conij). — Plilebitls  of  leg  delaying  convalescence  3  weeks. 

Retivit:  Oct.  28,  1916 — Some  swelling  of  left  leg  and  much  complaint 
of  the  tired  feeling  in  it.  Exam. — In  good  health.  Scar  O.  K.  Leg 
scarcely  swollen. 

267.  June  28,  1915.    Male — *6.    Cancer  of  lip.    Op.  (E.  A.  C.  and  A.  R.  B.) 
O  K  Local  anaesthesia — V-shaped  excision.    Comp. — None. 

Result:  Aug.  10,  1916— Exam.— Well. 

268.  June  28,  1915.  Male — 77.  Starvation  from  impassable  cancer  of  oesoph- 
agus.   B.  C.  H.  (No.  3219.39  and  No.  326916).    His  phys.  instructed  to 

p  J  feed  patient  through  hollow  bougies  constructed  after  the  method  of 

S.  J.  Mixter.    Great  relief. 

Result:  Aug.  10,  191.5 — Strength  failing,  but  able  to  keep  up  nourish- 
ment.   Died  Oct.  2,  1915,  at  B.  C.  H. 

269.  July  20,  1915.    Female — 58.    Intestinal  obstruction  from  cancer  of  the 
g_ip  rectum.  Op.  (E.  A.  C.  and  A.  R.  B.) — Large  inoperable  mass  at  recto- 

sigmoidal  junction.  Numerous  metastases  in  liver.  Artificial  anus  made 
p_j  in  left  loin.    Distal  end  closed  and  dropped  back. 

Result:  Aug.  30,  1915 — Has  returned  home,  but  strength  is  rapidly 
failing.    Died  of  the  same  disease  Jan.  18,  1916. 

270.  July  22,  1915.  Female — 62.  An  abdominal  tumor  larger  than  full-term 
uterus.  Pre-op.  diag. — Ruptured  papillomatous  cyst  of  ovary.  Op.  (E. 
A.  C.  and  A.  R.  B.) — Large  multilocular  cyst.  It  had  been  rui)tured 
to  some  extent,  and  the  jelly-like  contents  had  spread  about  abdominal 

O  K  cavity  and  in  places  had   become  encysted  again.    The  tumor  was  re- 

moved and  was  found  to  consist  of  numberless  spaces  filled  with  colloid 
material,  but  there  were  no  papilloma ta — only   thin   walls.    Neverthe- 
less, on  section  Dr.  J.  H.  Wright  considered  the  specimen  colloid  cancer. 
Comp. — None. 
Result:  Sept.  27,  1916— Well.    Scar  solid. 

271.  Aug.  6,  1915.  Female — 41.  Abdominal  pain  for  24  hours.  Pre-op.  diag. 
— Acute  appendicitis.    Op.   (E.  A.  C.  and  A.  R.  B.) — Gangrenous  ap- 

^  ^  pendix  removed  and  retrocecal  abscess  drained.    Comp. — None. 

Result:  Aug.  19,  1916— Exam.— Well.    Scar  solid. 

272.  Aug.  12,  1915.  Female — 31.  Attacks  of  biliary  colic  for  last  18  months. 
Pre-op.  diag. — Gallstones.  Op.  (E.  A.  C.  and  A.  R.  B.) — Novocaine. 
In  lower  portion  of  right  lobe  of  liver  hard  tumor,  size  of  lemon,  which 
seemed  adherent  to  gall  bladder.  No  stone  felt.  Closed  tight.  Opera- 
tive   diag. — Gun)ma    of   liver.    Comp. — During   convalescence,    pain    in 

E-d  feet  and  legs  without  swelling  or  phlebitis.    Cause  unknown — perhaps 

spinal.    Active  specific  treatment. 

Result:  Aug.  2,  1916 — Physician  reports  that  patient  has  never  enjoyed 
such  good  health.  Weight  153  pounds,  as  compared  with  108  pounds 
a  year  ago.  Pain  in  region  of  gall  bladder  has  gradually  grown  less 
severe,  the  intervals  increase;  no  attack  of  pain  for  three  months. 

273.  Aug.  14,  1915.    Male — 39.    Suppurating  wen,  size  of  horse-chestnut,  on 
fv   Tf            outer  side  left  thigh.    Op.  (E.  A.  C.  and  A.  R.  B.)— Novocaine.    Tumor 

excised  and  defect  closed  by  skin  flap.    Comp.— None. 
Result:  Aug.  8,  1916 — Well.    Scar  red,  but  not  troublesome. 

274.  Aug.  24,  1916.  Female — 41.  Large  fibroid  of  the  uterus  causing  severe 
menorrhagia  and  complicated  by  chronic  nephritis.  Op.  (E.  A.  C.  and 
A.    R.    B.) — Supravaginal    hysterectomy.    Large,    thickened    appendix 

EJ-C  removed.     Comj). — Slight    bronchitis.     Serous    discharge    from   wound; 

healed  in  2  weeks.  Angio-neurotic  edema  of  hands  and  feet  Albumi- 
nuria disappeared. 

Result:  Aug.  2,  1916 — Letter— "My  health  is  good." 

60 


276.  Aug.  27,  1915.  Female — tl.  Retrocecal  appendix  abscess  of  2  weeks' 
durntion.  Patient  had  previously  refused  operation.  Op.  (E.  A.  C.  and 
A.  R.  R.) — Airscess  drained,  hut  appendix  could  not  be  found  in  fibscess 
wall.  Conip. — A})pendicial  fistula.  Cystitis.  Aug.  18,  lOKJ — Hernia  in 
scar.  Still  has  a  very  small  appendiceal  sinus  wiiich  gives  her  a  great  p_j. 
deal  of  worry.  Aii])endectomy  advised.  Oct.  29,  1916 — Re-entered.  Op. 
(E.  A.  C.  and  W.  P.  Couesj — Excision  of  appendix,  which  had  been  £«__ 
drawn  to  the  siirface  l)y  a  fistula  and  appeared  almost  normal.  Ovarian 
cyst,  size  of  horse-chestnut,  excised  and  ovary  sutured.  Uterus  showed 
small  fibroids,  but  hysterectomy  not  considered  necessary.  Bad  hemor- 
rhoids treated  with  clamp  and  cautery.  Comp. — Exacerbation  of 
chronic  cystitis. 

276.  Aug.  31,  1915.    Male — 29.    Two  typical  appendlcial  attacks  previously. 
Op.   (E.  A.  C.  and  A.  R.  B.) — Local  anaesthesia.    Strictured,  adherent 
appendix    removed.    Comp. — Hematoma    in    wound,    but    no    delay    in    E-C 
convalescence. 

Result:  Aug.  7,  1916— Well.    Scar  solid,  slightly  keloidal. 

277.  Sept.  7,  1915.  Female.  This  patient  was  in  severe  shock  with  a  barely 
perceptible  pulse.  She  had  had  acute  abdominal  symptoms  for  20  hours; 
onset  sudden.  Feeling  that  the  diagnosis  was  uncertain  but  that  her 
critical  condition  rendered  a  rapid  exploratory  operation  imperative, 
I  called  Dr.  D.  F.  Jones.    His  diagnosis  was:    (1)    Perf.  appendicitis. 

(2)  Perf.  stomach  or  duodenum.  (.3)  Extrauterine  pregnancy.  Op.  O  K 
(Drs.  D.  F.  J.  and  J.  M.  G.) — Typical  ruptured  tubal  pregnancy  was 
found,  and  the  left  tube  and  ovary  excised.  Immediately  after  the 
operation,  Dr.  Beth  Vincent  performed  indirect  transfusion  from  the 
patient's  sister.  Patient  rallied  well,  and  had  a  comfortable  convales- 
cence. Comp. — None. 
Result:  Aug.  19,  1916— Physician  reports,  "Well." 

278.  Sept.  8,  1915.    Female — 42.    Multiple  tumors  in  both  breasts.    Pre-op. 
diag. — Double  chronic  cystic  mastitis.    Op.  (E.  A.  C.) — Amputation  of    v^ 
both  breasts.    One  tumor  proved  to  be  a  small  fibroma,  the  rest  were 
cystic.    Comp. — Slight  bronchitis.    Wound  O.  K. 

Result:  June  13,  1916— Well. 

279.  Sept.  13,  1915.  Female — 27.  Perineal  lacerations  following  confinement 
several  months  previously.  I  have  never  seen  such  an  extreme  case. 
The  rents  extended  on  each  side  practically  to  the  cervix,  and  backward 
into  the  rectum,  causing  incontinence  of  feces.  An  attempt  had  been 
made  by  the  attending  physician  to  sew  up  with  silk.  The  scars  were 
still  ulcerated,  and  hits  of  silk  protruded  here  and  there.  Op.  (E.  A. 
C.  and  A.  It.  B.) — The  entire  scar  tissue  on  both  sides  was  dissected 
out,  and  a  plastic  operation  done  which  repaired  the  sphincter,  vagina, 
and  perineum.  This  operation  was  very  extensive,  and  the  hemorrhage 
was  considerable.  Owing  to  these  conditions,  as  well  as  to  the  previous 
anemia  and  chronic  sepsis.  Dr.  Beth  Vincent  was  called  in  consulta- 
tion to  consider  the  question  of  transfusion.    This  operation  was  done, 

not  only  on  account  of  the  present  condition,  but  with  the  hope  of  aid-  g.^ 
ing  in  the  healing  of  the  very  extensive  wound.  No  test  for  hemolysis 
was  done.  The  donor  was  the  patient's  husband.  During  the  trans- 
fusion a  little  air  entered  the  vein,  but  no  immediate  symptoms  oc- 
curred. A  little  later,  however,  the  patient  had  a  severe  chill  and 
seemed  dangerously  near  complete  collajjse.  For  some  time  there  was 
methemoglobinuria.  We  felt  much  anxiety  as  to  her  condition,  but  she 
eventually  made  a  good  recovery.  Comp. — Slight  delay  in  healing  of  a 
portion  of  the  vaginal  wound.  Dr.  Vincent  found  that  the  donor's 
blood  belonged  to  Group  2  and  the  recipient's  to  Group  4.  This  ex- 
periment shows  that  even  in  this  unfavorable  combination  transfusion 
may  benefit. 

Result:  Aug.  18,  1916— Husband  reports,  "Fairly  well." 

61 


280.  Sept.  20,  1915.  Female — 27.  Jaundice.  Numerous  attacks  of  biliary 
colic  since  cholecystectomy  at  Mass.  General  Hospital  in  July,  1912 
(No.  \y.  S.  18318i).  Pre-op.  diag. — Obstruction  of  common  duct  from 
(1)  stone;  (2)  kinking  from  adhesions.  Op.  (E.  A.  C.  and  A.  R.  B.) 
— Duodenum  mobilized  and  common  duct  found  greatly  dilated  down  to 

•p,  a  strictured  point  just  at  the  edge  of  duodenum.    Adhesions  separated 

enough  to  free  this  obstruction.  Common  duct  was  not  opened.  Ab- 
dominal wound  closed.  Comp. — Slight  serous  discharge  for  2  days. 
Immediate  relief  of  symptoms. 

Result:  Aug.  7,  1916 — Physician  reports  that  "she  saj^s  she  is  quite 
well." 

281.  Nov.  17,  1915.  Male — 70.  A  left  inguinal  hernia  of  long  standing,  size 
of  two  fists.  Pre-op.  diag. — Hj'drocele  and  hernia.  Op.  (E.  A.  C.  and 
A.  R.  B.) — Spinal  anaesthesia  attempted  by  Dr.  Freeman  Allen,  be- 
cause patient  had  chronic  bronchitis  with  profuse  purulent  sputum. 
Anaesthesia  unsatisfactory,  so  anaesthol  was  used.  Tumor  proved  to  be 
wholly  a  hernia  of  small  intestine,  with  no  fluid  or  omentum.  It  mu^t 
have  contained  most  of  the  small  intestine.  Owing  to  the  size  of  the 
hernia,  the  chronic  bronchitis,  and  the  age  of  the  patient,  the  testicle 

*^'^  was  removed  and  the  canal  closed  tightly.    Comp. — Cough  very  severe, 

but  wound  healed  perfectly.  Great  improvement  after  syrup  of  hydri- 
odic  acid.  Aug.  18,  1916 — Exam. — Scar  solid.  Now  has  a  large  right 
inguinal  hernia.  Operation  advised.  Nov.  16,  1916 — Re-entered.  Scar 
of  former  operation  firm.  Op.  (E.  A.  C.  and  W.  P.  C.) — Novocaine. 
Radical  cure  of  hernia  by  Ferguson  method.  Testicle  was  not  removed. 
Comp. — Slight  hematoma;  entirely  healed  on  20th  day.  Chronic  bron- 
chitis still  persists. 
Result:  Jan.  15,  1917— Well. 

282.  Nov.  18,  1915.  Female — 55.  Recurrent  attacks  of  biliary  colic.  Pre-op. 
diag.— Gallstones.  Op.  (E.  A.  C.  and  A.  R.  B.)— Gall  bladder  was 
found  contracted  about  cluster  of  stones  and  densely  adherent  to  sur- 
rounding structures.  A  fistula  connected  it  with  the  duodenum.  Chole- 
cystectomy   and   suture    of    duodenal    fistula.    An    adherent,    partially 

g_j  obliterated  appendix  removed.    The  wound  was  badly  soiled  in  remov- 

ing gall  bladder,  and  three  drains  were  left.  Comp. — The  drains  were 
removed  on  the  5th  day,  which  proved  an  error  of  judgment,  because 
a  residual  abscess  formed  which  had  to  be  opened  with  the  finger  on 
the  16th  day.  This  delayed  the  patient's  convalescence  about  10  days; 
otherwise  there  was  no  complication. 
Result:  Feb.  22,  1917— Husband  reports,  "Well." 

283.  Nov.  18,  1915.  Female — 49.  Vague  abdominal  pain.  Chronic  discharge 
from  left  nipple.  Appendix  had  previously  been  removed  by  E.  A.  C., 
but  same  pain  persisted.  A  single  gallstone  shown  by  X-ray.  Pre-op. 
diag. — Gallstone,  pericecal  adhesions.  Op.  (E.  A.  C.  and  A.  R.  B.) — 
One  small  adhesion  of  omentum  to  appendix  scar  separated.    No  peri- 

E-c  cecal  adhesions   found.    Gallstone   removed   and   gall   bladder   drained. 

Comp. — None.    Consultation  with  Dr.   R.    B.   Greenough   in   regard  to 

E-d  breast,  which  he  considered  chronic  mastitis,  and  for  which  he  did  not 

advise  operation  at  present. 

Result:  Aug.  2,  1916 — "After  returning  home,  a  small  abscess  came  in 
the  scar."  Probably  due  to  a  tie.  "Soon  healed."  "Breast  continues 
to  discharge."    "Do  not  gain  as  I  wish  in  strength." 

284.  Nov.  22,  1915.  Female — 43.  Metrorrhagia  for  2  years.  Large  abdominal 
tumor  noticed  one  year.  Loss  of  strength.  Two  hard  nodules  size  of 
marble  in  old  scar  of  acute  appendix.  Op.  by  E.  A.  C,  Oct.  17,  1905, 
at  Mass.  General  Hosiiital  (No.  1-44820  E.  S.).  Pre-op.  diag.— Papil- 
lomatous ovarian  cyst  and  post-operative  hernia.  Op.  (E.  A.  C.  and  A. 
R.   B.) — Local  anaesthesia.    Appendix  scar   with   nodules   excised  and 

62 


ventral  hernia  repaired.  Exploration  with  finger  in  abdomen  showed  a 
large,  smooth,  movable  tumor,  also  whitish  nodular  metastases  in  the 
walls  of  both  large  and  small  intestines.  In  view  of  the  metastases 
present,  it  was  considered  unwise  to  remove  the  tumor.  The  specimens 
removed  with  the  scar  were  given  to  Dr.  J.  H.  Wright  for  pathologic 
examination.  He  submitted  the  following  report;  "Microscopical  ex- 
amination of  sections  from  the  two  fibrous  nodules  in  the  subcutaneous 
tissue  shows  the  following:  They  consist  of  connective  tissue  not  sharply- 
demarcated  from  the  surrounding  connective  tissue,  and  some  epithelial 
elements.  The  epithelial  elements  are  in  the  form  of  tubular  structures 
lined  with  cuboidal  or  cylindrical  epithelium.  These  structures  are 
disposed  singly  or  in  small  groups  well  separated  from  each  other. 
Immediately  about  the  tubular  structures,  in  many  instances,  is  an 
accumulation  of  cells  resembling  the  various  forms  of  cells  found  in  the 
interstitial  tissue  of  the  endometrium.  The  tubular  structures  them- 
selves, in  many  instances,  resemble  endometrium  tubules.  Some  of  the 
tubular  structures  are  quite  large  in  size,  and  there  is  considerable 
variation  in  their  size.  I  can  make  out  no  unstriped  muscle  fibres  in 
the  connective  tissue  which  makes  up  the  greater  part  of  the  tumors. 
The  microscopical  appearances  of  these  groups  of  tubular  structures, 
with  their  accompanying  cells,  are  very  like  those  of  the  islands  of 
endometrium  found  in  adenomyoma  of  the  uterus.  It  seems  possible 
that  tumors  in  this  case  are  of  the  nature  of  metastases  from  such  a 
tumor  of  the  uterus."  In  view  of  this  report,  and  of  the  fact  that 
adenomyoma  is  a  less  malignant  tumor  than  other  forms,  it  seemed  jj_j 
wise,  at  Dr.  Wright's  suggestion,  to  consider  removal  of  the  uterus. 
Accordingly,  a  consultation  was  held  with  Dr.  W.  P.  Graves,  who  g,g 
agreed  with  Dr.  Wright.  The  patient  was  sent  to  the  Good  Samaritan 
Hospital  (No.  2045)  to  recuperate  for  two  weeks,  and  then  returned 
for  operation.  Second  operation,  Dec.  21,  1915.  Op.  (E.  A.  C,  with 
the  assistance  of  Drs.  F.  H.  Pemberton  and  A.  R,  B.) — The  tumor, 
which  had  grown  into  the  broad  ligaments,  was  removed  without  much 
difficulty  by  supravaginal  hysterectomy.  After  removing  the  tumor, 
the  intestine  was  examined  with  great  care.  The  small  nodules  previ- 
ously seen  were  found  to  be  scattered  over  the  intestine,  especially  on 
the  transverse  colon,  which  was  in  one  place  almost  stenosed  by  little 
tumors.  The  appearance  of  these  nodules  was  unique  in  my  experience; 
they  resembled  somewhat  tuberculous  stricture  of  the  intestine;  they 
were  hard  and  malignant  in  feel.  Dr.  Wright  reported  in  regard  to 
the  large  uterine  tumor:  "Shows  nothing  but  plain  fibromyoma.  No 
endothelial  islands  found  anywhere."  Comp. — Phlebitis  of  the  femoral 
vein  delaying  convalescence  about  3  weeks.  During  convalescence  pus 
and  blood  were  found  in  the  stools,  and  the  patient  was  transferred 
to  the  Mass.  General  Hospital  (No.  206470),  to  be  under  the  care  of 
Dr.  Henry  F,  Hewes  for  a  more  careful  study  of  the  intestinal  con- 
dition. 

This  case  presents  a  peculiar  pathological  problem,  since  metastatic 
tumors  characteristic  of  a  certain  uterine  growth  were  found  in  scar 
tissue  at  a  distance  from  the  uterus,  which  itself  was  not  found  to  con- 
tain any  primary   growth,  which  may  have  given   rise  to  them.     The 
tumors  in  the  wall  of  the  intestines  were  not  identified,  so  that  it  must 
be  considered  probable  that  these  tumors   in  the  intestines   gave  rise 
to  the  metastases — if  so,  the  histologic  type  is  a  most  unusual  one. 
Result:  May  6,  1916 — Has  gained  16  pounds.    Looks  and  feels  well. 
285.  Nov.  29,  1915.    Female — 41.    Persistent  indigestion  of  the  flatulent  type, 
with  several  mild  attacks  of  abdominal  pain.    Gallstone  colic.    Pre-op. 
diag. — Peripyloric  adhesions  from    (1)  gallstones;    (2)  duodenal  ulcer;    -^a 
(3)   also  chronic  adherent  appendix.    Op.   (E.  A.  C.  and  A.  R.  B.)  — 
Obliterated  appendix  removed.    Post-inflammatory  adhesions  held  the 
first  portion  of  the  duodenum  to  the  liver  and  gall  bladder,  as  if  from 

63 


previous  perforation.  Adhesions  freed  and  a  small  induration  which 
I  considered  duodenal  ulcer  was  found  Just  below  the  pylorus.  Finney 
ojieration,  with  excision  of  a  jjortion  of  the  edge  for  microscopic  exam- 
ination. Conip. — None,  excei)t  a  good  deal  of  post-operative  vomiting. 
Pathologic  exam,  of  specimen  removed  showed  no  ulceration,  but  I  was 
convinced  clinically  that  I  could  see  a  very  small  ulcer,  through  which 
a  stitch  was  passed. 
Reault:  Nov,  30,  1916— Well. 

286.  Dec.  4,  1915.  Female— .39.  Under  care  of  Dr.  W.  P.  Graves.  Fibroid 
of  uterus.  Op.  (W.  P.  Graves  and  F.  H.  Pemberton) — Supravaginal 
hysterectomy.    Comp. — None. 

O  K  Result:  Mar.  28,  1917 — Well.    Scar  solid.    Twice  since  operation  a  swell- 

ing the  si/.e  of  a  half  horse-chestnut  has  appeared  near  lower  end  of 
wound;  it  lasted  a  few  weeks  and  then  disapjieared.  This  was  prob- 
ably cyst  formation  in  a  bit  of  transplanted  ovary.  On  each  occasion 
there  was  an  increase  of  hot  flashes. 

287.  Dec.  9,  191.5.  Female — 62.  Metrorrhagia  for  2  years.  Never  profuse 
or    prolonged.    Loss    of    weight    and    strength.    Diag. — Uterine   polyp. 

p_j  Operation  was  postponed,  because  sugar  was  found  in  the  urine. 

Reanit:  Aug.  2,  1916 — Physician  reports:  "Has  had  very  slight  bleed- 
ing on  two  occasions,  but  none  for  some  time.  She  l)ecame  sugar-free 
on  Allen  treatment,  and  remained  so  for  6  weeks,  but  now  she  shows 
some  sugar  on  a  modified  diet.    She  feels  at  present  quite  well." 

288.  Dec.  29,  1915.  Female — 46.  Under  care  of  Dr.  W.  P.  Graves.  Pre-op. 
diag. — Multiple  fibroids  or  ovarian  cyst.  Op.  (W.  P.  G.  and  F.  H.  P.) 
— A|)j>endectomy.  Supravaginal  hysterectomy  for  multiple  fibroids. 
Comji. — Mild  plilel)itis  in  calf  of  leg,  not  delaying  convalescence. 
Oct.  H,  1916 — Has  been  troubled  with  constipation  since  spring.  Weak- 
ness increasing.  Has  felt  unal)le  to  work.  Exam. — Tumor  palpable 
by  rectum  and  by  abdomen,  apparently  not  connected  with  cervix. 
Probal)le  diag. — Cancer  of  rectum.    Dec.   18,  1916 — Dr.  Graves  writes: 

"I  was  called  in  to  see  yesterday,  and  found  her  with  an  almost 

complete  obstruction  of  the  bowels.  On  account  of  the  emergency  of 
the  case  and  the  nearness  to  the  Free  Hospital,  I  took  her  there  and 
operated  on  her  tliis  morning.  I  found  the  abdomen  filled  with  huge 
adhesions,  thick  and  tough;  some  of  them  two  and  three  fingers  in 
breadth.    The  adhesions  were  scattered  about  and  did  not  seem  to  have 

^"C  any  particular  rehitionship  to  each  other.    The  chief  obstruction  was  in 

the   rectum,   iieginning  al)out  2   inches   from   the  anus,  the  rectum   and 

^"^'  sigmoid  being  twisted  several  times  on  itself  and  the  coils  attached  by 

these  extraordinary  adhesions  of  dense  scar  tissue." 

*^""'  "The  operation  was  an  extremely  difficult  one  and  took  me  nearly 

4  hours.  As  the  large  intestine  was  enormously  dilated,  and  the  patient 
has  a  very  small  abdomen,  there  was  nmch  exposure  of  the  intestinal 
content,  with  the  result  that  the  patient  left  the  table  in  profound 
shock.  I  have  never  seen  anytliing  like  this  case,  and  am  at  a  loss  to 
account  for  the  condition.  A  large  piece  of  tissue  attached  to  the  ab- 
dominal wall,  that  looked  and  felt  like  cancer,  sliowed  nncroscopically 
dense  filirous  tissue  with  areas  of  necrosis  and  calcification." 

Rexull:  Dec.  19,  1916 — "I  am  sorry  to  say  that died  24  hours  after 

tlie  o|)eration,  not  i)eing  ai)le  to  recover  from  shock.  There  was  no 
autojisy,  and  I  can  shed  no  further  light  on  the  cause  of  the  trouble. 
I  may  say  tliat  the  adiiesions  were  confined  entirely  to  the  large  intes- 
tine and  occurred  at  intervals  in  its  entire  Icnath  from  the  cecum  to 
amis.  It  seemed  to  lie  some  form  of  colitis.  She  passed  considerable 
gas  after  the  o])eration  and  some  black,  tarry,  fecal  matter  which  was 
jiresent  before  the  ojieration.  There  is  some  clinical  evidence  that  it 
might  have  been  a  progression  of  some  lesion  which  I  did  not  find  at  the 

64 


time  of  the  first  operation,  as  you  suggested.  She  was  not  relieved  of 
the  severe  constipation  which  she  had  before  that  operation,  and  it 
seemed  to  get  progressively  worse.  The  condition  is  one  with  which 
I  am  not  familiar." 

289.  Dec.  .31,  1915.  Female — 31.  Persistent  blood-stained  uterine  discharge. 
Had  previously  been  twice  curetted  by  other  surgeons.  Chronic  con- 
stipation, fatigue.  Poorly  nourished.  Pre-op.  diag. — Uterine  polyp, 
chronic  salpingo-ovaritis,  prolapsed  cystic  ovaries.    Ptosis.    Op.  (E.  A. 

C.  and  A.  R.  B.) — Supravaginal  hysterectomy.    Diag.  correct  in  detail,    p.^ 
Normal  appendix   also   removed.     Uterus  contained   a  polyp   attached 
high  in  fundus,  and  several  small  uterine  fibroids.    Comp. — None. 
Result:  Aug.  3,  1910 — Some  improvement,  but  still  very  nervous.    Has 
hot  flashes  and  constipation,  and  other  minor  troubles. 

290.  Jan.  4,  1916.  Boy  with  early  acute  appendicitis.  Transferred  in  a  few 
hours  to  the  Massachusetts  General  Hosi)ital,  because  his  father  would 
not  guarantee  the  hospital  fee.    M.  G.  H.  (No.  206079). 

291.  Jan.  12,  1916.  Female — 49.  Tumor  of  breast.  Pre-op.  diag. — Cancer, 
possible  adenoma  or  cyst.  Op.  (E.  A.  C.  and  A.  R.  B.) — Tumor  re- 
moved and  examined  immediately  by  Dr.  J.  H.  Wright,  who  considered 
it  non-malignant;  but  as  other  cysts  were  present,  whole  breast  gland 

,  and  adjacent  axillary  glands  removed.  Comp. — None.  Dr.  Wright's 
pathologic  report  follows:  ''I  have  prepared  paraffin  sections  from 
14  difi'erent  places  in  the  breast  of  case  291,  Jan.  13,  1916.  All  but  one  Q  g 
of  the  sections  show  appearances  of  chronic  proliferative  mastitis.  In 
one  small  section,  however,  there  is  a  small  area  which  is  clearly  of 
carcinomatous  nature."  In  view  of  this  report  and  the  early  character 
of  the  disease,  it  seemed  to  me  unwise  to  recommend  further  dissec- 
tion of  tiie  axilla,  although  at  tiie  original  operation  only  that  group 
of  glands  which  were  adjacent  to  the  breast  were  removed.  Comp. — 
None. 
Result:  Aug.  3,  1916— Letter— Well. 

292.  Jan.  14,  1916.  Male — 54.  Chronic  dyspepsia  for  many  years.  Blood 
pressure  220.  Worse  for  the  last  2  years.  Pre-op.  diag. — Ulcer  on 
gastric  side  of  pylorus,  possibly  malignant.  Op.  (E.  A.  C.  and  G.  F. 
Leland,  Jr.) — Indurated  ulcer  just  above  pylorus  was  removed  by 
partial  gastrectomy.  Comp. — Slight  serous  discharge  from  wound  in 
first  week.  No  j)us.  Pathologic  report  by  Dr.  Wright:  "The  piece 
of  stomach  wall  presented  an  irregular  ulcer  about  16  mm.  across.  The 
mucosa  in  the  neighborhood  was  elevated  and  the  wall  of  the  stomach 
beneatli  and  near  the  ulcer  was  thicker  than  normal.  Microscopical 
examination  of  paraffin  sections  involving  the  tissue  at  tlie  base  and 
margins  of  tiie  ulcer  shows  at  the  Ijase  fibrosis  and  chronic  inflamma- 
tory tissue.  At  tiie  margins  in  the  situation  of  the  mucosa  tiiere  is 
infiltration  with  atypical  epithelial  cells  arranged  in  columns  and  in  P-d 
irregular  tubules.    This  infiltration  apparently  does  not  extend  be3'ond 

the  limits  of  the  mucosa.    It  is  possible  th;it  we  have  in  this  case  an    E-c 
early  carcinoma.    1  cannot  convince  myself  that  the  atypical  cells  above 
mentioned  are  not  to  be  regarded  merely  as  manifestations  of  efforts 
at  repair  on  the  part  of  the  mucosa." 

Soon  after  the  patient  returned  home,  he  began  to  lose  ground  again 
for  some  imknown  cause,  ajiparently  business  worries.  The  gastric 
condition  had  improved,  liut  his  general  strength  did  not,  and  his  weight 
steadily  became  less.  He  returned  to  the  hospital  on  May  22,  1916, 
for  observation,  having  had  a  sudden  attack  of  hemiano])sia  2  weeks 
before.  Under  rest  and  enforced  feeding  iiis  condition  improved  for 
a  time,  l)ut  at  the  end  of  3  weeks  he  had  an  attack  of  facial  paralysis 
and  several  periods  of  cardiac  distress  accompanied  by  tachycardia. 
At  this  time  an  aortic  murmur  appeared.    He  was  transferred  to  the 

65 


Peter  Bent  Brigham  Hospital  (No.  9374)  on  June  21,  1916,  with  a 
diagnosis  of  endocarditis  and  emboli. 

Result:  Physician  reports  that  patient  died  of  lung  complications  on 
July  22,  1916.  Diagnosis  of  endocarditis  was  confirmed  by  autopsy. 
(Streptococcus  septicaemia  with  emboli.)    Scars  in  stomach  O.  K. 

293.  Jan.  21,  1916.  Male — 62.  Carbuncle  on  back  of  neck.  Chronic  nephritis. 
Treated  with  boric  acid  poultices  without  operation.    Comp. — None. 

p  ,  Result:  Aug.  3,  1916 — Well.    It  took  8  weeks  in  all  for  the  carbuncle 

to  heal.  After  it  healed,  two  others  came,  one  on  the  left  costal  border 
and  one  on  the  left  hand,  which  lasted  about  3  weeks.  Scar  is  incon- 
spicuous.   Nephritis  is  not  troublesome.    No  edema  of  ankles  or  face. 

294.  Jan.  31,  1916.  Male — 60.  Typical  case  of  subacromial  bursitis.  Pre-op. 
diag. — Calcification  beneath  base  of  subacromial  bursa.    Op.  (E.  A.  C. 

^  ir  a"d  A.  R.  B.) — Local  anaesthesia.    Bursa  incised  and  i  dram  of  cal- 

careous material  removed.    Comp. — None. 

Result:  Aug.  1,  1916 — Letter — "I  am  entirely  free  from  pain.  Recovery 
seems  permanent.  Motion  is  as  good  as  ever.  Playing  golf  better  than 
ever." 

295.  Feb.  1,  1916.  Male — 43.  Acute  abdominal  pain  for  24  hours.  Tender- 
ness in  small  mass  at  McBurney's  point.  Distention.  Pre-op.  diag. — 
Acute  appendicitis.  Op.  (E.  A.  C.  and  A.  R.  B.) — Tumor  proved  to 
be  a  mass  of  strangulated,  purple,  congested  omentum,  adherent  to  the 

ji  J  parietal  peritoneum   at  the  site  of  tenderness;  below  this  a  mass  of 

adhesions  constricting  ascending  colon.    The  affected  portion  of  omen- 
tum was  removed.    Appendix  long,  hard,  stiff,  and  full  of  concretions. 
Appendectomy.     Lane's    kink,    but    not    disturbed.     Post-op.    diag. — 
Torsion  of  omentum.    Chronic  appendicitis.    Comp. — None. 
Result:  Aug.  29,  1916— Exam.— Well.    Scar  solid. 

298.  Feb.  7,  1916.    Male — 54.     Cancer  of  lip;  small  lipomas  of  back  and 
shoulder.     Op.    (E.    A.    C.    and    A.    R.    B.) — Both   lipomas    removed. 
V-shaped  excision  of  lip  and  dissection  of  submental  glands.    Patho- 
O  K  logic  report  showed  cancer  of  lip,  but  tlie  glands  showed  no  evidence 

of  involvement.    Therefore,  a  thorough  dissection  of  the  neck  was  not 
done.    Comp. — None. 
Result:  Jan.  9,  1917— Well. 

297.  Feb.  10,  1916.  Female — 36.  Several  attacks  of  right-sided  abdominal 
pain.  Prolapsed  vaginal  walls.  Pre-op.  diag. — Chronic  appendicitis. 
Lacerated  cervix  and  peritoneum.    Op.  (E.  A.  C.  and  A.  R.  B.) — Re- 

O   K  moval  of  strictured  appendix  distended  with  clear  fluid.    Plastic  opera- 

tions for  cervix  and  perineum.    Comp. — None. 
Result:  Aug.  8,  1916— Letter— Well. 

298.  Feb.  16,  1916.  Female — 57.  A  slight  ulceration  on  the  right  edge  of 
the  tongue  opposite  a  sharp  tooth.  Pre-op.  diag. — Epithelioma  of 
tongue.  Op.  (E.  A.  C.  and  A.  R.  B.) — Excision  of  right  quadrant 
of  tongue  without  dissection  of  neck.  Pathologic  report  follows:  "The 
specimen  from  the  tongue,  case  298,  shows  hyperplasia  of  the  epithelium 
and  very  marked  infiltration  of  the  submucosa  with  plasma  cells  and 
cells  of  the  lymphocyte  series.    There  is  little  or  no  tendency  for  the 

O  ^  epithelium  to  invade  the  underlying  tissue.    I  am  unable  to  make  up 

my  mind  whether  this  specimen  represents  a  chancre,  a  leukoplakia  or 
a  beginning  carcinoma.  I  would  suggest  a  Wasserman  test."  A  Was- 
serman  test  was  negative.    Comp. — None. 

Result:  Feb.  26,  1917 — Physician  writes  that  patient  had  a  very  small 
ulcer  come  at  site  of  scar.  It  persisted  for  3  months  and  then  dis- 
appeared. 

56 


299.  Feb.  16,  1916.    Male— 57.    Mole  on  temple.    Op.  (E.  A.  C.  and  A.  R.  B.) 

— Excision.     Pathologic   report  by  Dr.   Wright — Papillomatous   mole,    q  ^ 

Comp. — None. 

Result:  Aug.  9,  1916— Letter— "Well. 

800.  Feb.  19,  1916.    Male — 5.    Tuberculous  glands  of  neck.    Previously  oper- 
ated on  by   E.  A.  C.  for  acute  abscess,  but  now  healed  and  showing 
tendency  to  increase.     Op.    (E.  A.  C.   and   A.   R.   B.) — Dissection  of   q  |j 
upper  half  of  right  neck.    Comp. — None. 

Result:  Sept.  11,  1916 — Exam. — Well.  Upper  part  of  scar  slightly 
keloidal. 

801.  Feb.  23,  1916.  Female — 4.4.  Small  tumors  in  both  breasts.  Pre-op. 
diag. — Cancer  of  right  breast  and  cystic  disease  of  both  breasts.  Op. 
(E.  A.  C.  and  A.  R.  B.) — Left  breast  removed  and  at  once  examined 
by  Dr.  Wright,  who  considered  the  specimen  suspicious  enough  to 
advise  dissection  of  axilla.  Right  breast  also  removed.  Comp. — None.  E-d 
Final  pathologic  report,  "A  number  of  sections  from  various  places  in 

the  breasts  show  a  good  deal  of  epithelial  proliferation,  but  nothing 
that  I  am  confident  is  carcinoma." 

Result:  Aug.  9,  1916 — Exam,  by  Dr.  B. — Scars  O.  K.  except  for  annoy- 
ing irregularity  in  one.    Otherwise  well. 

302.  Feb.  25,  1916.  Female — 44.  Persistent  abdominal  and  pelvic  pain. 
Worse  at  ctm.  and  sometimes  coming  in  severe  attacks.  Pre-op.  diag. 
— Uterine  fibroids.  Adhesions  right  ovary,  strictured  appendix.  Op. 
(E.  A.  C.  and  A.  R.  B.) — Complete  supravaginal  hysterectomy.  Uterus 
contained  many  small  fibroids.  There  was  a  hydrosalpinx  and  cystic 
left  ovary.  Strictured  appendix  removed,  and  also  two  gallstones  the  E-d 
existence  of  which  had  not  been  suspected.  Gall  bladder  was  drained 
through  a  stab  wound.  Comp. — Trifling  sepsis  in  median  wound.  Mild  ^'^ 
sloughing  about  drainage  tube.  Hot  flushes  and  erythema  with  intense 
itching. 

Result:  Aug.  3,  1916— Well.  Has  just  returned  to  work.  Dec.  9,  1916 
— Complains  of  tenderness  in  upper  wound  following  strain.  Exam. — 
WeU.    Scars  O.  K. 

803.  Feb.  27,  1916.    Male — 33.    Fistula  in  ano  of  4  months'  duration.    Op. 

(E.  A.  C.  and  A.  R.  B.) — Excision  of  fistulous  tract  and  cauterization    q  -^ 

of  hemorrhoids.    Comp. — None. 

Result:  Oct.  16,  1916— Friend  reports,  "Well." 

804.  Mar.  1,  1916.  Male — 45.  Many  vague  abdominal  symptoms.  Intro- 
spective. Came  for  thorough  examination.  X-ray  examination  sug- 
gested chronic  colitis.  A  greatly  enlarged  seminal  vesicle  was  found 
with  retention  of  spermatozoa,  but  no  pus.  Dr.  J.  D.  Barney  in  con-  P-d 
sultation.  Probable  diag. — Nephroptosis  and  kinking  of  right  ureter. 
Distended  seminal  vesicle.    Massage  advised. 

Result:  Jan.  31,  1917 — Somewhat  better  digestion,  but  otherwise  no 
marked  change. 

805.  Mar.    4,    1916.    Male — 53.    An   emergency   case   of   general    peritonitis 
with  classical  symptoms  of  board-like  rigidity,  collapse,  cyanosis,  and 
agonizing  pain.    Onset  sudden,  20  hours  before.    Had  not  called  physi- 
cian until  2  hours  before  arrival  at  hospital.    Pre-op.  diag. — Perforated 
duodenal  ulcer.    Op.   (E.  A.  C.  and  A.  R.  B.) — Perf.  gangrenous  ap-    P-d 
pendix  with  peritoneal  cavity  containing   free  pus  and  the  intestines   or 
distended  and  cyanotic.    The  gangrenous  appendix  was  found  to  have   g-s 
sloughed  off  at  the  base  and  several  large  concretions  lay  almost  free 

in  the  peritoneal  cavity.    Appendectomy  and  drainage.    Comp. — Oper- 
ation gave  no  relief;  intense  pain  continued;  peristalsis  did  not  start 
up;  persistent  vomiting — only  temporary  relief  by  lavage. 
Result:  Patient  died  on  4th  day,  in  spite  of  an  enterostomy  which  was 

67 


done  after  the  distention  became  so  severe  as  to  cause  the  prolapse  of 
a  coil  of  bowel  through  the  abdominal  wound. 

806.  Mar.  4,  1916.  Female — 63.  Adherent  subacromial  bursitis.  Massage, 
baking  and  exercise  with  considerable  relief. 

O  K  Result:  Aug.  3,  1916 — Letter — "Shoulder  is  very  much  improved,  but 

there  is  still  some  stiffness." 

807.  Mar.  5,  1916.  Female — 44.  Persistent  menorrhagia  for  2  years.  Pre-op. 
diag. — Intrauterine  polyp  and  intramural  fibroids.  Retroversion.  Op. 
(E.  A.  C.  and  A.  R.  B.) — The  appendix  was  full  of  soft  concretions; 

O  K  removed.    Supravaginal  hysterectomy  was  done  and  the  uterus  found 

to  contain  a  polyp  size  of  an  olive,  and  other  intramural  fibroids.  Comp. 
— None. 
Result:  Dec.  2,  1916— Physician  reports,  "Well." 

308.  Mar.  13,  1916.  Female — 65.  Abdominal  tumor  extending  from  pelvis 
2  inches  above  umbilicus.  Pre-op.  diag. — Fibroma  of  uterus,  or  cystoma 
of  ovary.  Op.  (E.  A.  C.  and  A.  R.  B.) — Tumor  proved  an  extensive 
mahgnant  mass  involving  all  pelvic  organs  and  invading  parietal  peri- 
toneum with  little  tubercles.  Piece  of  peritoneum  excised  and  reported 
adeno-carcinoma  (psammoma)  by  Dr.  Wriglit.  Condition  considered 
inoperable  and  abdomen  closed. 

On  reflecting  on  tiiis  case,  it  occurred  to  me  that  as  the  tumor  was 
evidently  partly  cystic,  it  might  be  possible  to  obtain  through  and 
through  drainage  and  treat  the  tumor  with  radium  from  inside  out 
through  the  pathway  thus  obtained.  The  patient's  relatives  were,  tliere- 
fore,  sent  to  consult  Dr.  H.  A.  Kelly  of  Baltimore,  Dr.  John  G.  Clark 
of  Philadelphia,  Dr.  Francis  D.  Donoghue,  and  Dr.  R.  B.  Greenough 
of  Boston,  to  see  whether  such  an  operation  would  be  justifiable,  and 
it  was  advised  that  the  attempt  should  be  made,  although  no  precedent 
existed. 

On    Mar.  22   I  operated    again   and   carried  a  large   rubber  tube 
through  the  mass  from  the  abdomen  out  the  vagina.    By  introducing 
radium    (obtained  through  the  courtesy  of  the  Huntington   Hospital) 
through  this  tube,  a  thorough  course  of  treatment  was  given. 
E-d  To  my  great  astonishment  the  bulk  of  the  tumor  vanished,  so  that 

at  the  time  of  her  discharge  on  June  29  there  was  only  a  small  pelvic 
mass  left.  From  being  moribund,  her  condition  had  become  one  of 
almost  perfect  health. 

After  this  siie  received  several  external  radium  treatments  at  the 
Huntington  Hospital  (No.  16.148)  which  were  unfortunately  followed 
by  a  severe  burn  of  the  abdominal  wall,  from  which  she  suffered  a 
great  deal. 

On  Mar.  21,  1917,  she  re-entered  for  treatment  of  the  radium  burns, 
wliich  proved  so  intractable  that  I  decided  to  excise  them.  At  this  time 
her  general  condition  was  excellent,  and  the  only  remains  of  the  original 
tumor  was  an  irregular  pelvic  mass  occupying  about  half  the  pelvis. 

Apr.  10,  1917.  Op.  (E.  A.  C.  and  G.  "a.  Leland,  Jr.)— The  burns 
were  excised  and  the  abdomen  opened.  The  pelvic  mass  seemed  oj^er- 
al)le,  and  after  a  five-hour  operation,  I  succeeded  in  removing  it  with 
the  uterus  and  adnexa.  To  my  great  surprise  the  peritoneum  now 
showed  no  trace  of  disease,  and  the  uterus  and  its  adnexa,  which  previ- 
ously were  indistinguishal)le  in  the  cancerous  mass,  were  now  plainly 
recognizal)le,  although  adlierent.  The  disease  seemed  wholly  confined 
to  tiie  ovaries,  wiiich  measured  7^  x  6i  x  4  cm.  and  8  x  6^  x  5  cm., 
respectively.  Vaginal  drainage  was  established,  and  the  abdominal 
wound  was  closed.  Tlie  ai)i)en(lix,  which  contained  a  concretion,  was 
not  removed.  Microscopic  examination  showed  that  the  ovarian  tumors 
resemhled  the  original  tumor,  but  the  cells  showed  no  metastases.  In 
the  abdominal  scar  a  few  small  areas  of  disease  were  also  found.  Comp. 

68 


— An  abscess   in  the  abdominal  fat  and  ^  very  small  recto-vaginal 

fistula. 

Result:  June  23,  1917 — The  wounds  have  healed  and  the  patient  is  in 

api)arently  good  health. 

It  is  interesting  to  note  also  that  a  small  pedunculated  fibroid  tumor 
which  was  present  at  the  first  operation  was  removed  at  the  last  oper- 
ation. It  showed  no  apparent  change  in  size,  in  spite  of  the  energetic 
radium  treatment. 

I  attribute  the  favorable  outcome  in  this  case  to  the  following 
factors : 

1.  The  tumor  could  be  treated  from  within  outward. 

2.  The  calcareous  deposits  by  the  cancer  cells  indicated  that  there 
was  a  tendency  towards  replacement  of  cancer  tissue  with  lime  salts. 

3.  The  calcareous  atoms  could  set  up  secondary  radiation. 

4.  Tlie  toxic  products  of  destruction  could  be  drained  away. 

6.  The  patient  had  already  shown  that  she  could  develop  a  very 
large  malignant  tumor  without  producing  general  cachexia. 

6.  Tlie  patient  herself  showed  indomitable  optimism  and  courage. 

The  writer  has  previously  had  two  surprising  cases  of  peritoneal 
cancer,  one  of  the  papillomatous  type.  The  patient  is  now  free  from 
the  disease,  16  years  after  the  original  laparotomy,  which  showed 
malignant  peritonitis.  The  other,  whose  peritoneum  showed  adeno- 
carcinoma, is  still  alive  and  free  from  the  disease,  7  years  after  an 
exploratory  operation.  In  the  first  case  drainage  was  established,  and 
after  10  years  a  secondary  operation  was  done  and  a  large  tumor  re- 
moved; but  in  the  second  case  no  treatment  was  given,  and  notiiing 
was  removed  except  a  piece  for  pathologic  examination.  Both  cases 
are  verified  by  sections  preserved  in  tlie  laboratory  of  the  Mass.  Gen- 
eral Hospital  (No.  167749)    (No.  664-327  E.  S.). 

809.  Mar.  15,  1916.  Male — 65.  Epidermoid  cancer  of  external  canthus  left 
eye,  size  25-cent  piece,  and  apparently  attached  to  the  malar  bone. 
Edema  of  conjunctiva.  Recurrent  from  operation  2  years  ago.  Ex- 
cision advised  by  E.  A.  C,  but  Dr.  R.  B.  Greenough,  who  was  called 

in  consultation,  advised  radium;  and  as  the  patient  preferred  not  to  be    ^~^ 
operated    on,    he   was    transferred   to   the   Huntington    Hospital,    and 
treated  by  radium  (No.  16.99). 
Result:  Dec,  1916 — Still  under  treatment  at  Huntington  Hospital. 

810.  Mar.  18,  1916.  Female — 39.  Acid  indigestion.  Hunger  pain.  Loss  of 
weight.  Weakness.  Inability  to  expel  feces.  Perineal  lacerations. 
Came  for  thorough  examination,  diagnosis,  and  advice.  Bismuth  exam- 
ination showed  no  abnormality  of  stomach  or  intestines.  Constipation 
entirely  due  to  inactivity  of  the  rectum,  probably  because  of  habit  and  q  jj 
slight  hemorrhoidal  condition.  Probable  diag. — Chronic  appendix  and 
possible  gallstones,  but  operation  was  not  urged  until  the  patient  had 
corrected  her  faulty  intestinal  habits,  to  see  whether  that  alone  would 

not  relieve  her  symptoms. 

Result:  Feb.  28,  1917— Much  better,  but  still  minor  stomach  symptoms. 

311.  May  23,  1916.    Male— 50.    Left  inguinal  hernia  for  about  2  years.    Op.. 

(E.  A.  C.  and  A.  R.  B.) — Local  anaesthesia.    Radical  cure  by  Ferguson    ^  x, 
method.    Comp. — None.  ^  ^ 

Result:  Mar.  8,  1917— Well. 

312.  Mar.  28,  1916.    Female— 16.    Acute  pain  for  7  days.    A  rounded  pelvic 
tumor  projecting  into  rectum.    Pelvic  and  left   abdominal  tenderness. 
Pre-op.  diag.— (1)    Impacted   ovarian  cyst.    (2)    Acute  appendix  with 
pelvic  abscess.    (3)   Tuberculous  peritonitis.    Dr.  A.  K.  Stone  in  con-    ^  ^ 
sultation  considered  acute  appendicitis  most  probable.    Op.   (E.  A.  C. 

and  A.  R.  B.) — A  large  pocket  of  odorless  pus  was  opened  and  drained. 
Origin  not  determined,  but  probably  appendicial.    It  was  felt  unwise 

59 


to  break  up  the  inflammatory  wall  to  remove  the  appendix.    Comp. — 

None. 

Result:  Oct.  25,  1916— Exam.— Well.    Scar  O.K. 

313.  Apr.  6,  1916.  Female — 20.  Persistent  metrorrhagia  for  2  months. 
Previous  irregularity.  Lacerated  cervix.  Pre-op.  diag. — Uterine  poljq). 
Op.  (E.  A.  C.  and  A.  R.  B.) — Internal  os  dilated  and  about  2  drams 
of  soft  material,  probably  polyp,  curetted  out.    Trachelorrhaphy.    Path- 

^   *^  ologic   report:  "Microscopic  examination  of  the  curetting  shows   that 

the  fragments  consist  of  rather  atypical  endometrium.  No  evidence  of 
malignant  disease."    Comp. — None. 

Result:  Sept.  16,  1916— Letter— Well,  except  for  feeling  "pretty  sick" 
at  last  ctm. 

314.  Apr.  8,  1916.  Male — 34.  Persistent  pyuria  and  dull  pain  in  left  flank. 
X-ray  showed  calculus  in  left  kidney.  This  case  was  previously  re- 
ported by  E.  A.  C.  in  the  Boston  Medical  and  Surgical  Journal, 
Vol.  clviii.  No.  22,  pp.  828-831,  May  28,  1908.  Patient  had  been  oper- 
ated on  for  intravesical  cyst  of  the  ureter,  which  was  removed  with  a 
large  number  of  calculi.    The  dilated  ureter  and  renal  pelvis  had  never 

E.j  returned  to  iiormal.    X-rays  had  been  taken  from  time  to  time,  but  not 

until  recently  did  they  show  any  calculus  formation.  Dr.  A.  L.  Chute 
in  considtation  advised  operation.  Op.  (E.  A.  C.  and  A.  R.  B.) — 
Nephrectomy.  The  ureter,  which  had  previously  been  so  much  dilated, 
was  found  to  have  contracted  to  approximately  normal  size.  In  spite 
of  the  presence  of  stone,  the  kidney  substance  appeared  normal.  Comp. 
— None. 
Result:  Aug.  3    1916 — Letter— Well.    "Urine  is  perfectly  clear." 

315.  Apr.  17,  1916.  Male— 62.  Under  the  care  of  Dr.  H.  H.  Haskell.  Senile, 
mature  cataract  of  left  eye.  Right  eye  had  previously  been  success- 
fully operated  on  by  Dr.  Haskell.  Comp. — Rupture  of  corneal  wound 
10  days  after  operation — the  wound  having  fully  healed  and  bandage 

E-c  omitted  3  days  previously. 

Result:  Sept.  7,  1916 — Physician  writes:  "Distant  vision  practically 
normal,  and  reads  smallest  print  easily.  He  hasn't  even  enough  astig- 
matism to  amount  to  anything,  although  a  prolapse  usually  causes  a 
high  degree.  Ord.  dist.  L.  V.  "3"  -}-  10.  =  -j-  l-^^  X  0'  =  part  of  1. 
Ord.  near.    L.  -|-  13.  =  -f-  1.50  X  0'  reads  diam. 

816.  Apr.  25,  1916.  Female — 52.  Abdominal  pain,  distress  and  distention 
10  days.  Not  severe  enough  to  make  her  call  a  doctor.  Rounded,  fluc- 
tuant pelvic  tumor,  size  of  two  fists.  Consultation  with  Drs.  C.  A. 
Porter  and  W.  P.  Graves.  Pre-op.  diag.  by  E.  A.  C. — Pelvic  abscess 
from  (1)  Appendix.  (2)  Salpingitis  with  ovarian  cyst.  By  C.  A.  P. 
— Tumor  connected  with  uterus,  tubo-ovarian,  perhaps  with  infection. 
By  W.  P.  G. —  (1)  Ovarian  cyst  with  ascites.  (2)  Edematous  fibroid. 
O  K  (3)  Tul)0-ovarian  cyst  or  abscess.    Op.  (E.  A.  C.  and  A.  R.  B.)— Right 

rectus  incision.  A  large,  foul  pelvic  abscess  opened  and  drained.  Con- 
sidered unwise  to  look  for  appendix  in  inflammatory  wall.  Comp. — 
None.  Superficial  wound  still  granulating  at  time  of  discharge,  June  13. 
Final  diag. — Probably  acute  appendicitis,  or  perforated  diverticulitis 
of  sigmoid.    Possibly  salpingitis. 

Result:  Mar.  19,  1917 — Slight  ventral  hernia  in  scar.  L^terus  adherent. 
Cervical  polyp  removed.  Feels  perfectly  weU.  No  symptoms  of  any 
kind. 

317.  Apr.   26,   1916.     Female — 33.     Menorrhagia.     Recently   discharge  of  a 
sloughy  membrane  through  os  uteri.    Pre-op.  diag. — Fibroids  of  uterus 
Q   j^  and  uterine  polyp.    Op.   (E.  A.  C.  and   A.  R.  B.) — Supravaginal  hys- 

terectomy, right  ovary  removed,  also  a  small  strangulated  hydatid  cyst. 
Left  ovary  in  situ.    Appendix  6  inches  long,  distended  with  old  feces, 

60 


adherent  and  kinked.    Uterus  on  section  showed  multiple  fibroids  and 

two  intrauterine  polj-ps.    Comp. — None. 

Result:  Sept.  1,  1916— Physician  reports,  "Well." 

318.  May  3,  1916.  Male — 48.  Tumor  in  central  portion  of  tongue,  size  of 
marble  and  hard.  4  weeks'  duration.  Pre-op.  diag. —  (1)  Chronic 
abscess.  (2)  Dermoid.  (3)  Cancer.  Dr.  J.  H.  Wright  present.  Local 
anaesthesia.    Tumor  incised.    Thick  pus  escaped.    Dr.  J.  H.  W.  reported 

that   section  of  wall  was  chronic  inflammatory  tissue  with  no  malig-    O  K 
nancy.    Comp. — None. 

Result:  Aug.  23,  1916 — Letter — "My  tongue  is  all  well,  does  not  bother 
me  in  the  least.  I  have  gained  17  pounds  since  I  entered  your  hospital, 
and  am  feeling  first  rate." 

319.  May  6,  1916.  Male — 44.  Loss  of  weight  and  strength.  Hyperacidity. 
Vague  abdominal  discomfort,  especially  in  right  iliac  fossa.  Patient 
apprehensive,  imagines  he  has  some  internal  disease.  Pre-op.  diag. — 
(1)   Cecum  mobile.     Chronic  appendicitis.     (2)   Cancer  of  cecum.     Op. 

(E.    A.   C.  and   A.   R.  B.) — Local  anaesthesia.    Appendix  sessile;  con-    P-d 
tained    several    fecoliths.     Cecum   mobile   and   general   visceral   ptosis. 
Pylorus  and  gall  bladder  normal.    Comp. — None. 

Result:  Feb.  28,  1917 — Better,  but  still  has  a  variety  of  vague  com- 
plaints. 

320.  May  20,  1916.  Female— 38.  Arthritis  of  both  knees  and  right  elbow. 
Both  knees  contracted  to  an  acute  angle,  cannot  be  straightened.  Dr. 
R.  B.  Osgood  took  charge  of  the  case.  Tonsils  which  were  buried, 
adherent  and  contained  suppurating  crypts,  were  removed  by  Dr.  J.  L. 
Goodale  without  comp.  Aug.  18,  1916 — At  time  of  discharge  from  p.j 
hospital,  condition  of  knees  greatly  improved — they  have  been  straight- 
ened, now  permitting  her  to  stand  on  her  feet  with  especially  con- 
structed splints. 

Result:  Apr.  16,  1917 — Letter — Still  suffering  from  multiple  arthritis. 
Unable  to  walk  without  crutches. 

321.  May  21,  1916.  Male — 63.  Pain  in  right  shoulder  and  inability  to  use 
arm  in  abduction  since  accident  2  years  previously.  Pre-op.  diag. — 
Ruptured  supraspinatus  tendon  (rt.).  Op.  (E.  A.  C.  and  A.  R.  B.) — 
Subacromial  bursa  incised.  The  whole  supraspinatus  was  found  to 
have  been  torn  from  the  tuberosity,  as  well  as  a  portion  of  the  infra- 
spinatus. A  remnant  of  the  supraspinatus  was  pulled  forward  and 
attached  with  silk  to  the  stump  of  the  tendon  still  left  on  the  tuber-  O  K 
osity.    The  arm  was  kept  in  abduction  for  2  weeks.    Comp. — None. 

Result:  Dec.  18,  1916 — Patient's  ability  to  use  arm  has  increased. 
External  rotation  and  abduction  are  now  nearly  normal  in  extent,  but 
the  motion  is  slow  and  irregular  and  lacks  power.  There  is  a  decided 
jog  as  the. tuberosity  passes  under  the  acromion.  Patient  states  that 
his  arm  is  decidedly  better  than  it  was. 

322.  May  22,  1916.  Female — 43.  Abdominal  pain,  leucorrhoea,  and  supposed 
tumor.  Patient  had  had  several  previous  abdominal  operations.  Dr. 
R.  B.  Greenough,  who  had  seen  patient  previously,  was  called  in  con- 
sultation. No  tumor  could  be  demonstrated,  and  a  provisional  diag.  O  K 
of  chronic  salpingitis  and  post-operative  adhesions  was  made,  but 
operation  was  not  advised.  Symptoms  subsided  under  rest  and  douches. 
Result:  Mar.  22,  1917 — Looks  and  feels  well.    Not  examined. 

323.  May  31,  1916.  Male — 60.  Large  carbuncle  back  of  neck.  Treated  ex- 
pectantly. Slow,  steady  improvement.  Small  granulating  area  at  time 
of  discharge  at  the  end  of  the  5th  week. 

Result:  Aug.  14,  1916 — Exam. — Since  leaving  the  hospital,  there  have    Q  jj 
been  a  few  furuncles  in  the  neighborhood  of  the  scar.    One  is  present 
today,  containing  a  drop   of  pus.     Scar  is  not  conspicuous.     General 
health  good. 

61 


324.  June  2,  1916.    Female — 26.  Alveolar  abscess  treated  by  her  own  dentist. 
O  K  No  op.    Comp. — None. 

Result:  Aug.  31,  1016 — Still  has  trouble  with  sinus. 

326.  June  9,  1916.  Male — 70.  Swelling  of  left  cheek,  one-half  size  of  fist, 
from  ulcerated  tooth  9  weeks  before.    Dr.  K.  H.  Thoma  in  consultation. 

^  _  X-rav  showed  an  unerupted  wisdom  tooth.    Bad  organic  heart  disease. 

^  '^  Op.   (K.  H.  T.)— Novocaine.    Tooth  chiseled  out.    Comp.— None. 

Result:  Dec.  22,  1916 — Pliysician  reports,  "Has  had  no  trouble  from 
his  jaw." 

326.  June  12,  1916.  Male — 49.  Pre-op.  diag. — Epithelioma  over  right  ear. 
Op.   (E.  A.  C.  and  A.  R.  B.) — Tumor  excised  and  the  gap  closed   by 

O  K  plastic  from  temple.  Comp. — None.  Pathologic  report — Papilloma  with 

malignant  change. 
Result:  Dec,  1916— Well. 

327.  June  13,  1916.  Male — 59.  Came  for  relief  of  pain  in  left  hip,  loss  of 
weight  and  strength.  Physical  examination  revealed  a  stricture  of  the 
rectum,  and  by  X-raj'  pathologic  changes  in  the  ischium  were  disclosed. 

P"d  Bit  of  rectal  mass  removed  proved  to  be  adeno-carcinoma.    Case  con- 

sidered inoperable — so  much  ulcerated  that  colostomy  was  unnecessary. 
Result:  Sept.  15,  1916 — Died  of  cancer  of  rectum. 

826.  June   19,   1916.    Male — 54.    Loss   of  weight   and  strength   for  2  years. 
Epigastric   pain    for    one   year.     Blood    present   in   stomach    contents. 
No   Hcl.    Palpable,   distended  gall   bladder.    Pre-op.  diag. — Cancer  of 
*'""  stomach.    Metastasis  in  liver  and  pre-pancreatic  glands.    Op.  (E.  A.  C. 

and    G.    A.    Leland,    Jr.) — Stomach    normal.    Gall    bladder    distended, 
stone  impacted  in  cystic  duct.    Cholecystectomy.    Comp. — None. 
Result:  Nov.  14,  19i6— Exam.— Well.    Scar  solid. 

329.  June  26,  1916.  Male — 22.  Unsightly  sinus  on  forehead  since  struck 
with  skate  2  years  ago.  There  has  been  a  small  sinus  which  opens  at 
intervals  and  discharges  crumbs  of  bone.  Op.  (E.  A.  C.) — Old  scar 
excised.  It  was  found  that  the  anterior  wall  of  the  frontal  sinus  had 
been  crushed  back  into  the  sinus.  As  no  definite  necrosis  was  found, 
it  was  thought  best  not  to  remove  any  of  the  bone.  Comp. — None. 
Result:  Aug.  29,  1916 — Father  reports,  "Has  been  quite  well  since  the 
operation,  and  the  scar  has  given  him  no  trouble." 

330.  June  28,  1916.  Female — 27.  Vague  abdominal  symptoms  and  neuras- 
thenia. While  waiting  for  operation,  developed  alveolar  abscess.  Ad- 
vised to  return  when  mouth  is  in  better  condition.  No  report,  and  did 
not  return. 

331.  July  6,  1916.  Female — 51.  A  large  pelvic  tumor  noticed  for  only  a 
week.  Has  been  poorly  for  6  months,  with  some  pain  in  the  epigastrium 
for  3  months.  Pre-op.  diag. — Uterine  fibroids  or  advanced  papilloma- 
tous cysts.    Op.  (E.  A.  C.  and  A.  R.  B.) — An  irregular  mass  of  cancer 

P-d  with  metastases  in  omentum  and  peritoneum.    Origin  could  not  be  de- 

termined.    Small    nodule    from    omentum    removed    for    examination. 
Pathologic   rei)ort    by    Dr.   J.    H.    Wright — Carcinoma.    Comp. — None. 
Transferred   to   Huntington   Hospital  for  radium  treatment,  July   18 
(No.  16.279;  118). 
Result:  Physician  reports  that  she  died  about  one  month  later. 

332.  July  27,  1916.  Female — 22.  Pre-op.  diag. — Dysmenorrhoea  from  ante- 
flexion.   Cervix  very  readily  dilated  and  uterine  cavity  curetted.    Left 

Tj.  J  ovary  could  be  felt  prolapsed  into  posterior  cul-de-sac.    Comp. — None. 

"  In  view  of  the  fact  that  the  os  was  readily  dilated  and  that  the  pro- 

p  J  lapsed   ovary   was    found,   the   proi)able   diagnosis   was    changed    from 

anteflexion   to  prolapsed   ovary,  but   the   result  of  the  operation  may 

determine  wlietlier  first  diag.  was  correct. 

Result:  Dec.  11,  1916 — Physician  reports,  "No  marked  improvement.'' 

62 


O  K 


P-r 


333.  July  9,  1916.    Male — 28.    A  septic  pilonidal  sinus  of  2  months'  duration. 

Op.  (E.  A.  C.  and  A.  R.  B.)— Excision  of  fistulous  tract.  O  K 

Result:  Aug.  29,  1916 — Still  granulating  spots. 

334.  July  10,  1916.  Female— 59.  Under  care  of  Dr.  K.  H.  Thoma.  Em- 
pyema of  left  antrum.    Pre-op.  diag. — Empj'ema  of  left  antrum,  tumor 

of   rigiit    antrum.     Op.    (K.    H.   T.) — Novocaine   in    spheno-maxillary   Q  jj 
fossae.    Both  antra  opened,  cleaned  and  packed.    There  was  empyema 
of  both,  and  a  large  polypus  in  the  right  one.    Comp. — None. 
Result:  Mar.  9,  1917— Healed,  Sept.  27,  1916. 

335.  July  18,  1916.  Male — 48.  A  right  inguinal  hernia  which  does  not  de- 
scend into  the  scrotum.  Op.  (E.  A.  C.) — Hernia  was  direct,  with  a 
double  sac  separated  by  the  epigastric  vessels.  The  bladder  formed  a 
part  of  the  wall  of  the  inner  sac.  The  fascia  and  muscles  were  infil- 
trated with  fat  and  were  so  poorly  developed  that  a  very  unsatisfactory 
closure  was  made.  The  cord  was  brought  out  at  the  upper  end  of  the 
wound  over  all  the  layers,  because  the  union  of  tlie  internal  oblique  Q  K 
with  Poupart's  ligament  seemed  too  flimsy  without  uniting  the  external 
oblique  to  it.    During  convalescence  a  small  tumor  in  the  skin  over  the 

left  outer  ham  string  was  removed  by  Dr.  Barrow.     This  tumor  Dr. 
Wright  reported  to  be  fibro-sarcoma.    Comp. — None. 
Result:    Aug.   6,   1916 — Exam. — Scars  O.K.     Exacerbation   of  hemor- 
rhoids which  have  bothered  him  for  years.    Operation  advised. 

336.  July  19,  1916.  Female — 61.  A  case  of  chronic  bacteriuria,  who  had  had 
several  previous  operations  at  the  Mass.  General  Hospital  (No.  157070). 
Came  for  cystoscopy  and  general  examination.  Cystoscopy  showed  p.(J 
bladder  almost  normal.  I  have  treated  this  patient  with  various  uri- 
nary antiseptics  for  years,  and  have  never  been  able  to  stop  the  bac- 
teriuria. At  one  time  the  ureters  were  catheterized  and  the  bacteria 
were  demonstrated  to  come  direct  from  the  pelves  of  both  kidneys. 
Result:  Feb.  1,  1917 — Condition  same. 

337.  July  19,  1916.  Male— 61.  Tumor  of  the  larynx  of  4  years'  duration. 
Hoarseness  and  dyspnoea.  Pre-op.  diag. — Cancer  of  the  thyroid  gland. 
Op.  (E.  A.  C.  and  A.  R.  B.) — Novocaine.  A  gland  about  the  si/.e  of 
a  robin's  egg  behind  the  left  sterno-mastoid  removed  for  pathological 
examination.  Dr.  "Wright  reports — Papillary  adeno-carcinoma,  prob- 
ably thyroid  origin.  Comp.— None.  Nov.  12,  1916— Referred  to  Hunt- 
ington Hospital. 

Result:  Feb.  26,  1917— Still  under  treatment  with  radium  at  Hunting- 
ton Hospital  (No.  16.482;  205). 

Reader! 

You  may  or  you  may  not  agree  with  the  criticisms  indicated  by  the 
symbols;  of  course,  they  are  open  to  doubt;  but  the  point  is  this: 

At  our  charitable  hospitals  there  is  no  one  who  dares  make  such  criti- 
cisms at  all.  It  is  the  duty  of  no  one  and  it  is  for  the  interest  of  no  one 
—  except  for  the  patients  and  for  the  community. 


P-d 


63 


THE  ADVANTAGES  OF  THE  END  RESULT  SYSTEM 
TO  SURGICAL  SCIENCE 

[Read  before  the  Surgical  Section  of  the  American  Medical  Association  on  June  7,  1917] 

My  premise  is  that  surgical  science  is  now  inaccurate  and  un- 
satisfactory, because  of  the  constant  necessity  which  the  practical 
surgeon  finds  of  compromising  with  accuracy  in  his  dealings  with 
human  nature.  I  claim  that  the  adoption  of  the  End  Result  System 
by  the  hospitals  of  this  country  will  at  the  same  time  render  our 
work  more  scientific  and  our  practice  more  efficient  and  honorable. 

I  define  surgical  science  as  that  surgical  knowledge  which  is 
recorded  and  transmissible  through  the  written  description  of  facts 
and  formulated  general  principles.  Clinical  science  comprises  all 
the  recorded  transmissible  facts  or  principles  which  enable  us  to 
apply  all  other  forms  of  human  science  to  the  cure  or  alleviation 
of  disease.  Human  science  means  all  the  recorded  knowledge  which 
is  available  to  the  human  race,  and  includes  all  the  various  branches 
— geology,  physics,  chemistry,  electricity,  etc.  It  is  the  sum  of  all 
the  ologies.  To  the  clinician  all  the  various  branches  of  science  are 
of  value,  and  his  true  success  depends  on  his  judgment  and  experi- 
ence in  applying  correctly  to  the  sick  patient  whatever  knowledge 
he  possesses  of  the  different  branches  of  science  which  humanity 
has  already  put  in  available  form. 

It  cannot  be  denied  that  man  possesses  a  wonderful  curiosity 
in  regard  to  the  facts  and  laws  of  nature.  It  is  a  part  of  his  enjoy- 
ment of  life  to  ascertain  and  to  classify  these  facts,  and  to  formulate 
into  laws  and  principles  the  data  which  observation  gives  him.  The 
truly  scientific  man  yearns  to  gaze  directly  at  the  truth,  but  there 
is  constantly  a  tremendous  temptation  for  him  to  deviate  from  his 
recognition  of  truth  or  its  application,  so  that  he  may  serve  what 
he  supposes  to  be  his  own  ends.  In  all  branches  of  science  one  sees 
the  observer  and  investigator  tempted  to  distort  what  he  knows  to 
be  the  fact  for  the  sake  of  his  own  purposes,  and  usually  for  the 
sake  of  his  own  support  in  the  struggle  for  existence.  In  no  other 
branch  of  science  is  this  struggle  between  the  effort  to  recognize  the 
truth,  and  the  practical  necessities  of  existence,  more  apparent  than 
it  is  in  the  practice  of  medicine.  It  might  almost  be  said  that  the 
man  who  is  successful  in  practice,  i.  e.,  in  applying  the  known  facts 
of  medical  and  surgical  science  to  the  actual  patient,  can  never 
confine  himself  to  definite  scientific  truth.  He  must  always  compro- 
mise with  human  nature  in  his  patients,  and  give  them  wliat  he  can 
of  truth  without  losing  their  confidence  in  him.  Most  practitioners 
claim  tliat  clinical  science  has  not  yet  arrived  at  a  point  where  it 
can  stand  on  its  own  feet,  as  do  many  of  the  other  sciences.  For 
instance,  in  mathematics  there  is  a  premium  on  accuracy,  while  in 
medicine  the  premium  is  on  the  successful  handling  of  each  par- 
ticular patient's  combination  of  character  and  pathology. 

64 


Life  is  so  full  of  deception,  and  human  nature  indulges  in  so 
many  curious  pretenses,  that  the  practical  man  in  any  form  of  busi- 
ness or  applied  science  cannot  help  feeling  occasionally  that  it  is 
useless  to  try  to  be  absolutely  accurate.  He  is  commonly  placed 
in  the  position  where  if  he  sticks  to  what  he  knows  to  be  the  accurate 
truth,  he  will  lose  the  business  which  might  help  him  make  his  living. 
It  even  may  be  said  that  the  great  majority  of  students  in  any 
branch  of  science  sooner  or  later  get  to  a  stage  where  they  feel 
that  the  effort  to  be  accurate,  logical,  and  sincere  is  hopeless;  they 
realize  that  practical  success  demands  an  adaptation  of  science  to 
the  immediate  question  which  they  call  practical.  But  when  one 
stops  to  think  whether  there  is  or  is  not  a  fund  called  human  knowl- 
edge, which  no  man  knows  in  its  entirety,  and  yet  which  is  available 
to  all  men,  one  must  acknowledge  that  there  is  such  a  fund.  There 
is  a  basis  of  recorded  truth  in  geometry,  in  bacteriology,  in  path- 
ology, and  in  the  other  sciences  from  which  we  may  draw.  Yet 
to  the  hypercritical  student  a  study  of  any  of  these  sciences  brings 
out  innumerable  inaccuracies.  There  is  no  branch  of  science  which 
is  complete,  and  yet  of  each  there  is  a  stock  of  knowledge  which  is 
recorded,  and  is  transmissible  from  teacher  to  student.  But  the 
deep  student  finds  that  there  is  always  an  indefiniteness  to  what 
knowledge  is  possessed  in  each  and  every  branch;  and  yet,  on  the 
other  hand,  his  study  leads  him  to  know  that  he  can  extract  from 
the  infinite  number  of  facts  and  principles  which  are  not  yet  formu- 
lated and  recorded  a  few  which  he  himself  can  drag  out  of  the 
darkness  and  put  on  record.  He  must  eventually  come  to  the  con- 
clusion that  the  finite  knowledge  which  man  possesses  is  infinitely 
imperfect,  but  that  the  infinite  knowledge  which  man  does  not  yet 
possess  can  be  made  finitely  perfect.  The  possession  by  humanity 
of  some  imperfect  knowledge,  already  too  vast  for  any  one  mind, 
is  a  proof  of  man's  ability  to  go  on  approaching  infinite  knowledge, 
which  is  the  truth.  Truth  is  the  one  thing  worth  clinging  to,  and 
is  too  evasive  and  difficult  to  grasp  to  let  any  opportunity  to  do  so 
slip  by.  Truth  subordinated  to  even  a  supposedly  good  purpose 
confuses  and  postpones  human  happiness. 

In  clinical  practice,  when  the  physician  or  the  surgeon,  for  the 
sake  of  his  own  reputation  or  even  for  the  sake  of  his  sympathy 
for  the  patient's  feelings,  resorts  to  subterfuges  or  worse,  the  ad- 
vance of  clinical  science  is  postponed.  And  if  the  advance  of  the 
science  is  postponed,  it  means  the  subtraction  of  the  opportunities 
to  use  that  which  is  postponed,  for  with  that  knowledge  relief  might 
be  given  to  future  sufferers.  The  physician  or  surgeon  who  sub- 
ordinates a  truth  to  his  fear  that  the  truth  may  be  misinterpreted 
is  actually  doing  harm  to  clinical  science.  In  a  broad  way,  the  effect 
of  this  practice  or  habit  of  the  profession  (for  I  believe  that  such 
subterfuges  are  common  enough  to  be  called  a  habit  of  our  profes- 
sion) can  be  illustrated  by  our  system  of  medical  education.  Medical 
science  and  medical  ethics  are  taught  by  precept  in  our  medical 

65 


schools,  but  in  our  hospitals  too  often  the  great  surgeon  or  teacher 
shows  the  student  by  demonstration  and  example  that  he  considers 
it  right  to  use  his  judgment  as  to  when  to  subordinate  truth;  and 
he  makes  pretty  free  use  of  this  form  of  poetic  license. 

If  a  sponge  is  lost  in  an  abdomen,  the  vmfortunate  fact  is 
concealed  as  thoroughly  as  possible.  For  fear  of  damage  to  the 
surgeon's  reputation  and  the  hospital's  reputation,  all  concerned 
are  agreed  that  it  is  better  that  the  patient  and  his  friends  should 
not  know  what  has  happened.  The  result  has  been  that  year  after 
year  has  gone  by,  and  no  adequate  measures  have  been  taken  to 
avoid  this  unfortunate  happening  in  many  hospitals.  The  lost  sponge 
in  the  abdomen  is  a  glaring  error,  obviously  preventable,  obviously 
a  proof  of  wretched  carelessness,  but  typical  of  the  mediaeval  state  of 
mind  which  permits  us  practitioners  from  the  highest  to  the  lowest 
to  defend  ourselves  under  the  old  saying,  "  Do  not  blame  the  doctor, 
he  does  the  best  he  can."  The  lost  sponge  is  only  a  glaring  example 
of  the  same  sort  of  inefficiency  as  a  careless  diagnosis,  a  hurried 
preparation,  a  reckless  operation,  or  a  whimsical  therapeutic 
experiment. 

But  you  will  ask  what  all  these  platitudes  on  philosophy  and 
morals  have  to  do  with  the  title  of  this  paper.  The  answer  is  the 
description  of  the  End  Result  System  of  Hospital  Organization. 
There  is  nothing  complicated  about  the  End  Result  System.  It  is 
merely  a  plan  for  giving  accurate,  available,  immediate  records  of 
each  case  which  the  hospital  undertakes  to  treat.  Its  unit  is  an  ideal 
result  for  each  individual  patient  treated.  It  subordinates  the  indi- 
vidual interests  of  the  staff,  if  those  interests  are  incompatible  with 
this  ideal ;  it  boldly  encourages  them,  when  they  are  not.  It  demands 
an  analysis  of  the  final  result  in  each  case  treated  and  the  fixation 
for  responsibility  of  failure  or  success  on  the  individual  who  under- 
takes the  treatment.  Such  a  system  is  truly  scientific.  Science  is 
simply  a  record  of  truth.  Science  demands  the  facts  about  each  case 
and  their  fearless  record,  even  if  brief.  Efficiency  demands  the  best 
possible  application  of  recorded  knowledge  to  each  case. 

I  find  there  is  a  constant  confusion  between  the  essential  ideas 
of  the  End  Result  System  and  the  Follow-Up  System.  The 
Follow-Up  System  is  only  a  step  in  the  End  Result  System. 
The  cases  should  be  followed  up,  to  see  whether  the  treatment  given 
has  or  has  not  been  successful.  The  End  Result  System  demands 
an  analysis  of  the  reasons  Avhy  the  case  has  been  successful  or 
unsuccessful,  and  the  utilization  of  the  knowledge  thus  obtained 
for  avoiding  future  errors  and  for  securing  future  successes.  The 
Follow-Up  System  is  a  useful  but  not  an  absolutely  necessary  part 
of  the  End  Result  System,  because  a  great  majority  of  the  cases 
can  be  determined  as  successful  or  unsuccessful,  even  as  early  as  the 
time  when  they  leave  the  hospital.  An  analysis  of  the  causes  of 
the  success  or  failure  in  these  cases  can  be  made  even  without  in- 
cluding any  of  the  cases  which  leave  the  hospital  and  are  followed 

66 


up  afterwards.  But  the  more  that  are  followed  up  and  included, 
the  better.  It  is  obvious  that  the  more  effective  the  Follow -Up 
System  is,  the  more  useful  and  satisfactory  will  be  the  conclusions 
formed  on  the  analysis  of  the  cases  in  general.  However,  I  coald 
write  an  End  Result  Report  for  the  cases  in  any  hospital,  everi  if 
no  FoUow-Up  System  existed. 

The  really  difficult  thing  about  the  End  Result  System  is  to 
induce  the  staff  in  any  hospital  to  be  willing  to  make  a  truthful 
acknowledgment  of  the  personal  part  which  contributes  to  the  suc- 
cess or  failure  of  the  cases.  It  is  here  that  we  meet  the  conflict 
between  man's  insatiable  desire  to  ascertain  the  truth  and  his  sup- 
posed necessity  to  deceive  his  fellowmen  for  the  sake  of  his  own 
self-preservation  or  ambition.  In  every  hospital  there  are  certain 
cases  where  the  personal  element  is  the  cause  of  failure.  The  onu? 
caused  by  the  fixing  of  responsibility  in  such  cases  is  so  great,  that 
it  really  does  bring  up  the  question  of  the  actual  struggle  for  exist- 
ence. Yet  if  we  all  permitted  this  fixation  of  responsibility,  this 
onus  would  be  pretty  well  distributed. 

Now  since  the  End  Result  System  demands  accurate,  available, 
immediate  records  for  scientific,  efficient  analysis,  it  must  also 
demand  a  classification  and  an  index  of  the  individual  pathologic 
conditions  which  the  hospitals  treat.  There  must  be  some  practical 
method  by  which  we  can  turn  to  any  given  class  of  cases,  in  ordei 
to  find  the  methods  of  treatment  which  have  been  effective  in  any 
group.  If  a  case  of  papilloma  of  the  bladder  enters  the  hospital, 
we  should  be  able  to  turn  at  once  to  the  records  of  all  cases  of  this 
condition  which  the  hospital  has  previously  treated,  in  order  to  make 
immediate  use  of  what  knowledge  we  have  obtained  from  the  thera- 
peutic experiments  we  have  performed  on  these  previous  cases.  We 
should  be  able  not  only  to  ascertain  the  methods  of  treatment,  but  the 
persons  under  whose  responsibility  the  choice  of  method  and  its 
successful  or  unsuccessful  application  was  made  in  each  case.  We 
want  a  simple  method  of  finding  out  who  has  been  successful  in 
treating  these  cases  and  how  he  did  it.  The  first  thing  is  to  be  able 
to  find  the  cases.  I  wish  to  suggest  the  practical  value  of  using 
classifications  as  indices  and  vice  versa.  But  classifications  and 
indices  will  be  of  little  use,  unless  there  is  a  premium  for  those  who 
use  them.    A  seniority  system  of  promotion  does  not  require  them. 

Classifications  are  only  relatively  useful.  Where  the  number  of 
patients  is  small,  the  number  of  subdivisions  of  classification  need 
not  be  large.  The  greater  the  number  of  patients,  the  greater  the 
number  of  subdivisions  needed  in  a  classification.  My  suggestion 
is  to  use  classifications  as  we  do  the  indices  in  books.  We  use  an 
index  in  a  book,  in  order  to  make  it  easy  to  turn  to  a  page  where 
a  certain  subject  is  mentioned.  It  is  on  the  page  referred  to  that 
we  find  out  how  much  and  how  detailed  that  information  is.  An  index 
in  a  book  may  be  classified,  and  still  be  equally  satisfactory  as  a 
rapid  method  of  leading  us  to  the  desired  information.    The  system 

67 


of  classification  which  I  propose  is  simply  to  record  each  case 
under  a  number,  like  a  page  in  a  book.  Each  case  will  have  an  index 
reference  to  every  anatomic  and  pathologic  diagnosis  which  is  men- 
tioned in  the  description  of  the  case.  The  index  itself  will  merely 
be  classified  anatomically  and  pathologically,  instead  of  alphabeti- 
cally. In  this  way  it  will  be  easy  to  find  from  the  index  every  case 
in  which  any  particular  disease  occurred.  For  instance,  suppose 
Case  161  had  appendicitis,  cholelithiasis,  and  fibroid  tumor  of  the 
uterus.  In  looking  in  the  index,  we  shall  find  after  each  of  these 
diagnoses  the  number  161.  By  using  the  same  method  of  classifica- 
tion of  indices,  we  may  make  them  practical  for  large  or  small 
hospitals,  large  hospitals  merely  having  more  subdivisions. 

How  shall  we  make  a  classification  of  the  index?  We  must  here 
again  return  to  the  finite  and  the  infinite.  I  call  your  attention  to 
the  fact  that  if  you  take  a  straight  line  and  divide  it  into  halves, 
and  one-half  of  this  line  into  other  halves,  and  so  on  indefinitely, 
you  will  arrive  at  what  is  called  in  mathematics  a  Variable  which 
approaches  its  Limit.  You  can  keep  on  dividing  the  half  into  other 
halves  indefinitely  to  the  end  of  time,  theoretically,  but  practically 
you  will  be  limited  by  the  number  of  visible  subdivisions  you  can 
make  with  your  pencil.  When  we  come  to  any  kind  of  classification, 
we  can  use  this  same  principle.  By  turning  the  line  into  a  square,  we 
can  make  our  classification  a  double  one;  and  by  turning  it  into  a 
cube,  a  triple  one. 

BASIC  PLAN  OF  A  CARD  CATALOGUE  CABINET 
FOR  STANDARD  HOSPITAL  USE 


^ 

'MAU6NANT 

OTHER  CONDITIONS              \ 

1 

1 

1 

\ 

A  suggestion  for  a  System  of  Classification  and  Case  Reference  Index 
of  Diseases,  based  on  the  principle  of  the  Variable  increasing  toward  its 
Limit,  which  acknowledges  that  the  Finite  is  infinitely  imperfect,  but  be- 
lieves that  the  Infinite  may  be  made  finitely  perfect. 

Consecutive  and  permanent  case  numbers  are  essential.  Begin  a  new 
series  on  January  1,  1918. 

68 


Such  a  classification  is  scientific.  It  acknowledges  the  infinite 
and  the  finite,  and  admits  the  impossibility  of  excluding  the  in- 
finite from  the  finite  or  the  finite  from  the  infinite.  To  make  a 
practical  classification,  we  need  merely  to  subdivide  "other  condi- 
tions" still  further  pathologically  and  anatomically.  That  any  finite 
classification  will  be  infinitely  imperfect  can  readily  be  seen  by  the 
subdivisions  in  figure  No.  1.  For  instance,  anatomically  we  divide 
into  "the  head"  and  "other  parts  of  the  body,"  but  where  shall  we 
say  that  the  head  is  defined.^  How  much  of  the  neck  shall  we  in- 
clude.'* Is  the  pharynx  part  of  the  head  or  of  the  neck?  Likewise 
in  the  pathologic  classification  we  divide  into  "malignant"  and 
"other  conditions" — shall  we  include  mixed  tumor  of  the  parotid 
as  a  malignant  condition  ?  Who  knows  ?  We  have  not  yet  defined 
the  answer.    The  infinite  has  not  become  finite. 

No  more  can  we  deny  the  finiteness  of  the  infinite,  for  we 
certainly  can  divide  "other  parts  of  the  body"  into  the  trunk  and 
"other  parts  of  the  body,"  and  we  can  divide  "other  pathologic 
conditions"  into  inflammatory  conditions  and  "other  pathologic  con- 
ditions." I  hold  that  the  most  human  science  can  do,  is  to  make  the 
infinite  more  finite,  for  the  sciences  of  mathematics  and  philosophy 
show  us  that  space  and  time,  squares  and  circles,  embody  the  in- 
finite and  finite.  We  may  suppose  a  circle  which  surrounds  the  most 
infinite  record  of  knowledge  the  human  mind  is  capable  of  knowing, 
and  we  may  likewise  suppose  an  inner  circle  which  bounds  the 
knowledge  which  man  has  already  accumulated — human  science. 
It  is  the  growth  of  this  inner  circle  of  finite  knowledge  toward  the 
outer  circle  of  infinite  knowledge  which  represents  the  development 
of  the  human  mind.  It  gives  us  satisfaction  to  make  the  inner  circle 
expand  toward  the  outer  circle.  Life  may  be  truly  happy,  when 
human  science  has  reached  the  outer  circle  and  contains  all  that  the 
human  collective  mind  can  know  of  Truth,  collected  and  arranged 
in  available  form  for  the  individual. 

In  this  large  chart  which  I  present  to  you  (see  loose  leaf),  I  offer 
a  practical  classification  suited  to  our  present-day  knowledge  of 
anatomy  and  pathology,  in  the  intersecting  squares  of  which  are  the 
numbers  of  the  cases  which  have  been  operated  upon  at  my  own 
hospital.  This  classification  and  index  are  useful  to  me  as  far  as 
my  limited  knowledge  goes.  It  enables  me  to  turn  at  once  to  any 
rare  case,  or  to  all  the  cases  of  any  particular  diagnosis  which  have 
fallen  within  my  experience  at  the  hospital.  It  is  useful  to  me  alike 
in  studying  the  scientific  side  of  my  cases  or  the  practical  efficiency 
of  the  treatment  which  I  have  given.  The  whole  chart  and  each  sub- 
division in  it  contain  the  same  relation  of  the  finite  and  the  infinite. 
So  far  as  my  pathologic  and  anatomic  knowledge  are  finite,  it  is  accu- 
rate ;  but  like  all  things  in  human  science,  it  is  infinitely  imperfect 
and  inaccurate.  I  merely  claim  that  it  is  a  step  in  the  right  direction ; 
that  it  accords  with  the  circle  which  represents  human  knowledge 
growing  toward  the  great  outer  circle  which  represents  all  possible 

69 


human  knowledge.  This  chart  could  be  subdivided,  so  that  its 
divisions  -would  be  so  detailed  that  one  division  would  be  found  for 
self-inflicted  gunshot  injuries  of  the  little  toenail,  or  it  could  be 
condensed  to  the  limits  of  the  four-square  chart  shown  above. 

In  a  large  hospital,  one  can  imagine  this  chart  forming  the  face 
of  a  filing  catalogue  in  which  each  drawer  would  have  the  label  of 
each  subdivision.  If  each  drawer  then  took  advantage  of  the  third 
dimension,  further  subdivision  could  be  carried  on,  and  an  almost 
infinite  number  of  cases  could  be  catalogued  in  it. 

If  a  hospital  had  such  a  card  catalogue  painstakingly,  accurately, 
and  infinitely  subdivided,  it  would  be  of  no  use  unless  the  human 
spirit  in  that  hospital  were  willing  to  acknowledge  and  record  its 
errors,  and  to  persistently  analyze  their  causes,  in  order  to  take 
steps  to  prevent  them  in  the  future.  The  seniority  system,  nepotism, 
and  humbug  would  be  gradually  crowded  out  of  such  a  hospital. 

Unless  we  use  a  merit  system  of  promotion  instead  of  a  seniority 
system,  there  will  be  little  incentive  for  clinical  accuracy.  The 
struggle  for  existence  must  he  utilized  to  give  the  truthful  and 
efficient  an  opportunity  to  survive.  Like  the  individuals  in  the  coral 
reef,  each  must  be  made  to  add  his  bit  to  the  advance  of  clinical 
science.  Human  nature,  particularly  young  human  nature,  wants 
to  play  the  game  according  to  the  rules.  If  it  has,  or  can  acquire, 
merit,  it  wants  that  merit  recognized  and  honored,  whether  paid  or 
not  paid.    The  pay  is  an  added  proof  of  the  justice  of  the  honor. 

Imagine  nepotism  and  seniority  in  our  National  Game,  either 
in  the  amateur  or  professional  field !  The  work  in  a  hospital  is  no 
less  a  team  game,  and  the  practice  of  surgery  would  be  a  far  more 
interesting  profession,  if  the  game  were  played  fairly.  It  needs 
supervision,  referees,  and  rules,  because  if  human  nature  needs  them 
in  play,  it  certainly  needs  them  in  the  struggle  for  existence. 


70 


ESSENTIAL  STEPS  IN  THE  END  RESULT  SYSTEM 
FOR  THE  USE  OF  CARDS  AND  CHART 

Treatment  should  not  be  undertaken  without  diagnosis.  A  per- 
son who  takes  the  responsibility  of  treatment  should  not  object  to 
stating  what  diseases  or  conditions  he  thinks  he  is  treating.  He 
should  not  object  to  stating  the  symptoms  from  which  he  seeks  to 
relieve  the  patient^  nor  to  having  the  hospital  and  the  public  know 
whether  or  not  he  succeeded  in  relieving  these  symptoms.  He 
should  be  willing  and  glad  to  state  his  general  line  of  treatment 
or  the  essential  findings  and  steps  of  his  operation,  and  to  record 
under  his  own  signature  any  complications  which  result. 

If  in  the  organization  of  a  hospital,  diagnosis,  treatment,  after- 
treatment,  and  follow-up  examinations  are  each  made  by  different 
persons,  each  should  sign  under  the  appropriate  heading. 

If  in  a  hospital  these  conditions  are  insisted  upon,  the  members 
of  the  staff  have  a  right  to  expect  the  administration  to  pay  the 
expenses  of  following  up  their  cases  and  of  giving  each  the  credit 
for  his  successes  in  the  Annual  Report  of  the  institution. 

Each  patient  who  enters  the  hospital  shall  have  one  number  and 
one  number  only,  no  matter  how  many  times  he  enters. 

The  End  Result  Cards  should  be  authoritative — signed  by  the 
persons  responsible  for  saying  what  was  the  matter  with  the  patient 
and  for  directing  the  treatment  given. 

End  Result  Cards  should  be  filed  numerically  and  have  a  name 
index.    When  a  case  is  once  reported  dead,  file  separately. 

The  End  Result  Card  is  intended  to  be  an  epitome  of  the  entire 
record  of  the  life  of  one  individual  patient,  so  far  as  that  life  comes 
in  contact  with  the  hospital. 

The  ideal  scientific  record  would  be  a  complete  description  of 
the  individual  from  his  conception  to  his  grave,  together  with  all 
pathologic  conditions  which  arise  in  consequence  of  congenital 
deviations  from  the  normal  or  in  consequence  of  any  reaction  to  his 
environment. 

In  the  present  conditions  of  human  society,  extensive  records  in 
hospitals  are  impracticable  except  in  a  few  instances.  But  extensive 
records  are  not  necessary  for  science — brief,  authoritative,  accurate, 
fearless  records  of  important  facts  are  needed  in  clinical  work  today. 

Our  effort  in  designing  an  End  Result  Card  has  been  to  make  a 
record  so  brief,  that  any  hospital,  however  small,  can  use  it  as  well 
as  a  big  hospital.  It  is  intended  to  be  the  greatest  common  divisor 
of  all  clinical  records. 

Therefore,  do  not  crowd  it,  but  arrange  the  important  facts  so 
clearly  in  your  brain,  that  you  can  place  them  within  the  dimensions 
of  this  card. 

71 


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DIRECTIONS  FOR  FILLING  OUT  CHART 

When  100,  or,  if  you  please,  1,000  cards  have  accumulated, 
let  two  persons  enter  the  diagnoses  in  the  appropriate  intersect- 
ing squares  of  the  Chart.  One  (preferably  a  doctor)  may  read  the 
diagnoses,  no  matter  how  many  there  are  on  a  card;  the  other 
(preferably  an  accurate  accountant)  may  enter  the  number  of  the 
card  in  the  appropriate  intersecting  squares  for  each  diagnosis. 
When  an  operation  has  been  done,  he  may  underline  the  number 
with  red  ink.  If  the  patient  died  in  the  hospital,  he  may  bracket 
with  black  ink.  When  more  than  one  diagnosis  should  appear  in 
the  same  square,  add  -2  or  -3  or  -m  =  multiple  to  the  card  number. 

The  whole  can  be  verified  by  reversing  the  process  and  calling 
the  numbers  from  the  squares  and  checking  each  card. 

When  the  squares  become  crowded,  use  a  new  sheet  and  enter 
the  last  number  in  the  upper  left-hand  corner. 

Or  if  only  one  or  two  squares  are  crowded,  enter  them  separately 
at  the  bottom  of  the  sheet. 

Re-entries  should  have  new  diagnoses,  entered  on  the  old  charts. 

In  entering  numbers  which  are  large,  as  224342,  only  the  last 
one,  two,  or  three  figures  need  be  entered,  because  the  thousands 
will  be  given  from  the  upper  left-hand  corner.  If  you  now  have 
these  cumbersome  large  numbers,  give  them  up  and  start  fresh. 


SUGGESTIONS  AND  PRECEDENTS  FOR  THE 
RECORDING  CLERK 

These  may  be  increased  in  number  by  rulings  of  the  Efficiency 
Committee  of  any  individual  hospital,  and  such  rulings  added  to 
their  reports. 

Gallstones  and  other  calculi  should  be  classed  under  "chronic 
inflammation." 

Displacements  of  organs  under  "unclassified,"  unless  considered 
"congenital"  or  "traumatic." 

Perineal  lacerations  should  appear  under  "traumatic." 

Abdominal  adhesions  under  "unclassified  abdominal,"  unless  the 
organs  involved  are  specified;  e.g.,  the  gall  bladder  being  adherent 
to  the  pylorus  would  be  classified  under  chronic  inflammation  of  both 
regions,  but  if  caused  surely  by  cholecystitis  or  duodenal  ulcer,  it 
would  fall  under  the  appropriate  organ  only. 

Inguinal  and  femoral  herniae  should  appear  under  "traumatic" 
of  groin,  vmless  specified  as  "congenital." 

Post-operative  herniae  should  appear  under  "unclassified  abdom- 
inal" and  "traumatic." 

If  in  doubt,  reserve  for  the  decision  of  the  EflSciency  Committee. 

See  also  pages  78-85. 

74 


VARIOUS  USES 

As  An  Index 

If  one  desires  to  look  up  all  the  cases  of  a  given  disease  of  a  given 
region,  say  tuberculosis  of  the  wrist,  he  must  look  through  all  the 
cards  whose  numbers  appear  in  the  intersecting  squares  of  Tuber- 
culosis and  Joints.  To  be  sure  that  the  recording  clerk  has  not  put 
any  cases  under  other  headings,  he  might  also  look  through  Bones ; 
but  with  the  double  check  mentioned  above,  the  clerk  would  be 
unlikely  to  put  such  a  case  in  any  other  square. 

Large  hospitals  having  a  card  index  could  use  this  sheet  as  a 
basis  for  their  card  index  and  subdivide  to  any  extent  under  it,  either 
anatomically  or  pathologically. 

For  Morbidity  Statistics 

The  footing  up  of  individual  squares  and  vertical  and  transverse 
columns  and  their  totals  give  statistics  of  all  sorts,  both  of  the  inci- 
dence of  a  given  disease  and  of  the  number  of  cases.  A  given  case 
may  have  tuberculosis  of  the  intestines  and  of  the  wrist,  and  thus 
be  recorded  as  an  instance  of  each  of  these  diseases,  and  yet  the 
investigator  would  easily  see  that  both  instances  occurred  in  one 
patient. 

For  Mortality  Statistics 

Mortality  appears  in  the  chart  in  relation  to  the  disease,  to  the 
combination  of  diseases,  to  the  operation,  to  the  individual,  and  to 
the  hospital.  To  obtain  the  mortality  in  a  column  or  in  the  whole 
sheet,  it  is  merely  necessary  to  make  a  list  of  all  black  bracketed 
numbers  and  to  check  off  the  duplicates. 

If,  as  we  suggest,  in  addition  to  the  tables  every  hospital  pub- 
lishes abstracts  of  every  fatal  case,  as  in  the  Massachusetts  General 
Hospital  report,  the  investigator  can  make  up  his  own  mind  as  to 
whether  he  regards  the  death  as  due  to  any  single  pathologic  con- 
dition or  to  the  operation  or  to  some  inter-current  calamity. -"^ 

For  End  Result  Records 

On  the  chart  itself  or  on  a  duplicate,  which  is  easily  made,  one 
may  record  at  the  end  of  any  given  period,  say  a  year,  the  fact  of 
whether  the  result  of  the  treatment  is  known  or  not  known.  This 
may  be  done  by  drawing  a  blue  line  through  the  number.  Every  case 
that  turns  up  after  that  date  may  be  marked  with  a  blue  line  on 
the  old  chart  by  the  clerk  who  records  the  note  on  the  End  Result 
Card. 

"■  In  the  chart  here  given,  black  brackets,  red  underlining,  etc.,  have  been  omitted  to 
prevent  confusion. 

75 


As  An  Efficiency  Study 

The  Efficiency  Committee  may  use  a  duplicate  chart  to  mark  each 
number,  with  a  colored  line  denoting  satisfactory  or  unsatisfactory 
results. 

It  should  be  the  aim  of  every  hospital  to  have  every  square  con- 
spicuous by  the  presence  of  O.  K.  marks  or  by  the  absence  of  the 
marks  denoting  errors  of  judgment,  skill,  care,  and  equipment. 

For  the  teaching  hospitals,  the  Efficiency  Committees  should  also 
aim  to  have  some  numbers  in  every  square. 

Private  hospitals  will  inevitably  aim  for  a  high  percentage  of 
satisfactory  marks. 

Charitable  hospitals  should  have  the  difficult  squares  well  filled 
and  be  able  to  show  that  the  deaths  were  under  the  care  of  men  who 
had  previously  established  good  records  in  similar  cases. 


OBJECTIONS  TO  USE  OF  CHART 

1.  It  is  too  complicated. 

Answer.  Try  it  for  one  month  and  really  see  if  it  is. 

2.  It  is  too  expensive. 

Answer.  Try  it  for  a  year  and  see  if  it  does  not  save  the  cost  in  the 
elimination  of  waste  products. 

3.  It  is  too  difficult  for  a  house  officer  to  decide  which  squares 
to  put  the  diagnosis  in. 

Answer.  Then  let  the  senior  surgeon  do  it,  for  it  is  the  most  impor- 
tant work  in  a  hospital  to  make  sure  of  a  good  Product. 

4.  Members  of  the  Staff  themselves  would  not  know  which 
square  to  put  a  given  diagnosis  in,  and  would  not  use  it  after 
it  is  done. 

Answer.  Then  get  a  staff  who  can  do  it,  and  who  will  use  it. 

5.  A  large  hospital  would  use  up  the  sheets  too  rapidly. 
Answer.  Large  hospitals  should  use  the  chart  as  a  basis  for  a  card 

index  system. 

6.  Special  hospitals  would  fill  up  some  squares  to  overflowing 
and  have  few  in  the  rest. 

Answer.  Each  special  hospital  could  use  one  sheet  for  all  its  diag- 
noses except  those  in  the  squares  of  its  specialty,  and  devise  a 
still  further  subdivided  sheet  for  its  special  cases. 

7.  It  does  not  give  the  sex  or  age. 

Answer.  No,  nor  the  birthplace,  nor  the  color  of  the  hair  and  eyes. 
Nevertheless  it  is  practical,  if  you  are  in  earnest. 

76 


THE  CHART  IN  PRINT 


The  chart  itself  is  perhaps  a  cumbersome  thing  to  print,  although  it  is  very 
useful  in  filing  the  niunbers.  In  a  printed  report,  however,  the  numbers  can  appear 
just  as  well  under  printed  headings.  As  an  illustration,  I  present  the  following 
table,  which  the  reader  can  use  to  look  up  any  pathologic  condition  in  this  Report, 
although  not  as  rapidly  as  on  the  chart,  which  has  many  subheadings.  It  would, 
however,  be  merely  a  matter  of  printer's  ink  to  put  the  whole  chart  in  this  form. 
You  can  use  this  table  as  an  index  to  common  conditions,  rare  conditions,  or  un- 
named conditions.  Try  it.  Find  the  cases  of  empyema,  elephantiasis  of  the  legs, 
or  buckling  of  the  liver.  To  locate  the  cases  of  empyema,  you  would  have  to  look 
through  all  the  numbers  under  inflammatory  conditions  of  the  thorax;  but  to  find 
any  other  inflammatory  condition  of  the  thorax,  you  would  only  have  to  look 
through  the  same  numbers.  Thus  time  and  space  are  saved,  unless  the  index  is 
in  very  frequent  use. 

Why  have  a  long  list  of  names  in  a  report,  except  to  impress  the  Trustees? 
Why  invest  in  expensive  card  catalogues? 


New  Growths 

Bead 

10,  41,  46,  55,  61,  65,  78,  79,  96, 
133,  143,  146,  149,  1S6,  197,  223, 
251,  252,  261,  267,  296,  298?, 
299,  309,  326,  334,  837 


Thorax 

38,  39,  51,  78,  114,  119,  197,  268, 

278,  291 


Abdomen 

4,  19,  29,  43;  53,  68,  78,  87,  99, 
106,  110,  124,  145,  151,  159,  173, 
185,  204,  211,  226,  230,  231,  232, 
237,  242,  253,  255,  256,  258,  265, 
266,  269,  270,  274,  275,  284,  286, 
288,  289,  292,  802,  307,  808,  317. 
331 


Trunk 

53,  68,  85,  136,  151?,  168,  218, 
237,  258,  269,  287,  289,  296,  807, 
311,  313,  317,  827 


Extremities 

16,    52,    60,   148,   257,   259,    262, 

273,  296,  335 


General  or  Unclassified 

or  Affecting  All  or  Many  Parts 

of  the  Body 


Inflammatory  Conditions 

Head 

2,   3,   16,  27,  30,  63,  67,  69,  71, 

86,   89,   127,   142,   157,   171,    177, 

184,  186,  193,  250,  293,  298,  300, 

315,  318,  320,  323,  324,  325,  330. 

334 

Thorax 

4,  24,  28,  30,  36,  45,  46,  77, 
80,  86,  88,  92,  96,  114,  121,  125, 
127,  137,  138,  152,  165,  174,  189, 

190,  200,  201,  224,  244,  246,  252, 
262,  274,  278,  281,  283,  291,  292, 
293,  301,  325 

Abdomen 

1,  7,  13,  14,  16,  18,  19,  21,  24, 
25,  26,  31,  33,  36,  42,  49,  50,  53, 
56,  64,  74,  76,  77,  78,  84,  87, 
89,  90,  93,  94,  102,  113,  115, 
116,  117,  121,  122,  124,  126,  129, 
138,  140,  141,  142,  151,  155,  156, 
158,  159,  163,  166,  167,  168, 
175,  176,  178,  179,  182,  183,  188, 
189,  192,  193,  195,  196,  200,  202, 
203,  208,  211,  212,  215,  219,  220, 
221,  222,  223,  224,  225,  226,  230, 
233,  234,  235,  236,  240,  242,  243, 
248,  249,  250,  254,  255,  256,  266, 
271,  272,  274,  275,  276,  280,  282, 
283,  285,  288,  289,  290,  292,  295, 
297,  302,  304,  305,  307,  308,  310, 
312,  SIR,  317,  319,  322,  328 

Trun  1: 

5,  6,  7,  8,  11,  13,  17,  34,  44,  45, 
53,  76,  80,  95,  103,  107,  109,  111, 
136,  139,  148,  160,  164,  166,  168, 
171,  172,  178,  194,  214,  217,  223, 
244,  245,  247,  250,  253,  274,  275, 
293,  303,  314,  333 

Extremities 

24,    40,    57,   111,    112,    130,  131, 

141,  144,  150,  160,  171,  187,  189, 

191,  205,  206,  214,  216,  221,  227, 
228,  229,  239,  252,  259,  264,  266. 
273,  284,  288,  293,  294,  306,  S20, 
321 

General  or  Unclassified 

or  Affecting  All  or  Many  Ports 

of  the  Body 

62,  81,  97,  100,  125,  162,  249,  292 

77 


Other  Conditions 
Bead 

2,  12,  22,  43,  66,  70,  73,  79,  91, 
142,  146,  186,  233,  253,  292,  325, 
829 


Thorax 

13,    45,   54,    156,    159,    224,    238, 

252,  264,  292 


Abdomen 

7,31,  33,  35,  36,  48,  50,  53,  68,  77, 

94,   103,  105,  110,   116,  117,  121, 

135,  138,  140,  142,  151,  152,  155, 

156,  178,  179,  189,  196,  200,  211, 

218,  219,  220,  221,  222,  224,  234, 

236,  237,  250,  255,  258,  269,  275, 

277,  280,  284,  288,  289,  295,  308, 
319,  322 


Trunk 

13,  17,  26,  29, 
47,  58,  59,  72, 
101,  103,  104, 
134,  139,  154, 
170,  171,  172, 
193,  194,  199, 
233,  234,  236, 
260,  264,  275, 
303,  304,  308, 
314,  332,  333, 


30,  32,  34,  35,  37, 

82,  83,  94,  95,  96, 
121,  128,  129,  132, 
164,  167,  168,  169, 
176,  178,  180,  192, 
207,  208,  213,  230, 
241,  250,  253,  255, 
279,  281,  287,  297, 
309,  310,  311,  313, 
335,  336 


Extremities 

9,   15,   23,   51,   75,   98,   108,  112, 

118,  120,  129,  130,  141,  147,  153, 

174,  181,  191,  198,  205,  209,  210, 

216,  221,  228,  238,  239,  255,  256, 
263,  264,  274,  294,  321 


General  or  Unclassified 

or  Affecting  All  or  Many  Parts 

of  the  Body 

8,   18,    20,   49,   76,   96,   123,   161, 

168,  233,  241,  250,  264,  274,  287, 

304,  309,  330 


The  Educational  Factor  in   Placing  the   Diagnoses 
ON  THE  Chart 

The  person  who  uses  this  chart  should  be  willing  to  admit  that 
a  straight  line  has  no  width  and  may  extend  to  infinity  at  either  or 
both  ends.  But  he  must  also  admit  that  he  can  practically  make  a 
straight  line  a  foot  long  and  the  width  of  a  pencil  mark.  He  can 
be  more  sure  that  the  postulated  straight  line  has  no  width  than  he 
can  of  the  width  of  the  pencil  mark.    Yet  both  are  real  to  him. 

Thus  in  filling  out  the  chart,  he  may  be  sure  that  the  postulated 
distinctions  are  correct,  and  equally  sure  of  his  inability  to  accu- 
rately place  each  diagnosis  in  the  appropriate  squares.  However, 
the  inaccuracy  in  most  cases  will  not  be  his  fault,  but  that  of  present- 
day  medical  science.  It  is  well  enough  to  entitle  one  space  "head" 
and  another  "neck,"  but  more  difficult  to  decide  in  which  the 
pharynx  or  parotid  belongs. 

In  the  case  of  a  cystic  cervix,  it  is  hard  to  make  up  one's  mind 
whether  to  class  it  as  a  "new  growth"  or  a  "chronic  inflammatory" 
condition.  The  decision  would  depend  on  the  degree  of  knowledge  we 
possessed  about  the  origin  of  cystic  disease  of  the  cervix,  or  of  the 
opinion  of  the  person  making  the  classification.  Personally,  I  con- 
sider it  usually  "chronic  inflammatory."  However,  all  knowledge  is 
subject  to  the  same  restrictions  of  our  lack  of  power  to  separate  the 
finite  from  the  infinite,  but  that  we  can  to  some  extent  is  certain. 

It  is  on  this  general  principle  that  the  subdivisions  of  both  the 
anatomic  and  pathologic  conditions  have  been  thought  out.  Ordi- 
nary methods  of  classification  have  been  made  by  names,  and  the 
names  have  been  subdivided.  Unfortunately  the  names  of  symptoms, 
pathologic  conditions,  and  anatomic  regions — three  different  things 
— have  been  subdivided  as  if  they  were  one  thing.  True  subdivisions 
should  divide  a  homogeneous  thing.  Separation  is  a  different  thing 
from  division.  Two  kinds  of  fluid  may  be  mixed  in  a  bowl.  We  may 
divide  the  whole  fluid  into  halves,  but  each  half  will  contain  the 
same  proportion  of  each  ingredient  of  the  mixture.  True  separation 
would  withdraw  one  kind  of  fluid  from  the  mixture  and  leave  the 
other.  We  apply  this  method  to  the  previous  methods  of  classifica- 
tion. Others  have  gone  on  making  subdivisions  of  mixtures,  whereas 
we  separate  the  different  ingredients.  When  wood  and  iron  are 
mixed,  we  do  not  divide  tlie  two  together,  but  we  separate  our  wood 
from  iron.  So  the  subdivisions  in  our  chart  and  tables  would  more 
properly  be  called  subseparations. 

We  are  always  separating  each  ingredient  from  the  mixture  as 
fast  as  science  will  permit  us ;  and  there  will  always  be  left  a  group 
of  conditions  which  are  unclassified  anatomically  or  pathologically, 
in  the  lower  right-hand  corner  of  the  chart.  We  think  that  all  the 
other  rectangular  spaces  in  the  chart  represent  the  separations  that 
science  has  already  attempted  to  make  from  this  chaotic  group  of 
"unclassified  unclassified  conditions."    But  the  same  principle  that 

78 


applies  to  the  whole  chart  applies  to  each  individual  separate  rec- 
tangle. Each  rectangle  will  always  be  capable  of  further  subdivision, 
and  it  will  always  have  a  lower  right-hand  corner  in  which  the  "un- 
classified of  unclassified  conditions/'  under  its  own  heading,  should 
fall.  The  whole  is  a  Variable  increasing  toward  its  Limit,  and  each 
subdivision  is  another  Variable.  Like  all  human  experience,  the 
chart  is  full  of  mistakes  and  errors,  but  the  mistakes  may  always 
be  remedied  or  at  least  acknowledged. 

In  descriptive  science,  to  name  a  condition,  a  division,  a  group, 
or  any  sort  of  subdivision,  appears  to  be  a  natural  process  of  human 
thought.  We  name  the  condition,  so  that  for  the  time  being  we  can 
tell  one  another  about  it ;  but  another  group  of  men  in  another  place 
may  name  the  same  thing  or  condition  by  a  different  name.  Hence 
the  growth  of  languages,  the  confusion  of  the  tongues  of  Babel,  and 
the  oft-quoted  question,  "What's  in  a  name.''" 

As  a  matter  of  fact,  there  are  many  pathologic  conditions  which 
have  many  names,  and  others  which  have  no  names.  This  is  partic- 
ularly so  when  there  are  combinations  of  different  conditions.  A 
method  such  as  the  one  described  permits  the  reader  to  use  this 
classification  as  an  index  to  find  even  these  many  named  or  unnamed 
conditions  which  in  an  ordinary  tabulation  would  be  relegated  to 
miscellaneous  conditions.  For  example.  Case  221  is  so  unusual  a 
condition,  that  it  has  no  name.  It  was  a  buckling  of  the  edge  of  the 
liver  due  to  ptosis  of  the  liver,  while  the  edge  was  held  high  by  an 
epigastric  scar.  Even  though  there  is  no  name  to  use,  we  unhesi- 
tatingly place  it  as  a  traumatic  condition  of  the  digestive  glands 
(liver). 

Is  the  attempt  to  do  this  apparently  tedious  work  worth  while? 

The  stupendous  task  of  making  a  science  of  clinical  medicine 
is  to  apply  all  the  other  sciences  to  neutralizing  all  the  noxious 
effects  which  heredity  and  environment  may  thrust  upon  the  indi- 
vidual by  all  sorts  of  detailed  combinations  of  diseases  in  any  portion 
or  many  portions  of  the  body.  And  the  science  of  preventive  medi- 
cine implies  even  a  further  knowledge — so  thorough  an  understand- 
ing of  disease  and  anatomy,  that  the  two  can  be  prevented  from 
combining.  When  this  millennium  can  be  attained,  the  whole  chart 
will  be  separated  and  subseparated  to  an  infinite  degree — except  a 
theoretic  space  in  the  lower  right-hand  corner. 

We  may  deny  the  possibility  of  ever  reaching  perfect  knowledge, 
but  we  cannot  deny  that  we  have  begun  to  try  to  do  so.  Human 
knowledge  has  begun  in  the  upper  left-hand  corner.  We  have  already 
described  and  formulated  much  of  our  environment.  We  can  al- 
ready apply  our  knowledge  to  curing  and  preventing  some  noxious 
influences.  Is  not  the  beginning  of  the  chart  quite  as  wonderful  as 
the  end  is  likely  to  be  ?  To  my  mind,  the  effort  to  fill  out  the  chart 
is  a  pleasurable  one — only  annoyed  by  my  errors  of  inaccuracy. 
I  feel  that  while  I  stick  by  what  I  know  to  be  true,  correct,  and 
accurate,  I  am  in  accord  with  the  evolution  of  humanity,  and  am 

79 


contented.  But  when  haste,  fatigue,  inaccuracy,  laziness,  or  ambition 
hurry  me  into  error,  I  get  out  of  tune,  and  must  penitently  go  back 
for  the  false  notes.  And  a  real  error — one  done  with  intent  to  deceive 
— the  sacrifice  of  a  truth,  no  matter  how  good  the  cause — would 
strike  a  discord  in  the  harmony  of  the  universe.  It  would  ring 
loudest  in  my  own  ears,  but  my  neighbors  might  suffer  too. 

There  are  many  doubtful  conditions,  some  of  which  are  still 
imclassified,  because  we  do  not  know  their  pathology  accurately, 
even  though  they  are  familiar  enough  as  clinical  entities.  The  fol- 
lowing are  some  of  the  conditions  which  have  caused  me  trouble, 
and  on  which  I  have  established  precedents  for  myself  which  may 
help  others.    My  doubt  has  been  due  to  my  imperfect  knowledge. 

Inguinal  and  femoral  hernia  can  be  anatomically  defined  under 
groin,  but  there  is  doubt  of  their  pathologic  position.  They  are 
sometimes  congenital  and  sometimes  traumatic  conditions,  and  some- 
times actually  inflamed  or  strangulated.  In  the  present  state  of  my 
pathologic  knowledge,  I  prefer  to  class  them  as  "traumatic,"  unless 
they  are  obviously  "congenital,"  i.  e.,  the  sac  continuous  with  the 
tunica  vaginalis. 

A  ventral  hernia  following  appendectomy  or  other  abdominal 
operation  is  clearly  "traumatic."  In  the  chart  previously  published 
I  classified  such  cases  when  following  appendectomy  as  "traumatic 
of  the  appendix,"  but  I  think  it  is  less  confusing  to  consider  them 
as  "traumatic  of  the  unclassified  abdomen,"  and  shall  do  so  in  the 
future. 

Shall  cystocele  be  classified  as  a  lesion  of  the  female  genitals 
or  of  the  urinary  organs?  It  is  clearly  a  "traumatic  condition  of 
both  genitals  and  urinary  organs,"  but  primarily  of  the  former. 
I  therefore  classify  it  as  "traumatic  of  the  female  genitals";  if 
cystitis  were  superimposed,  I  should  classify  it  also  as  "acute  or 
chronic  inflammatory  of  the  urinary  organs." 

Should  anteflexion  and  retroversion  be  classed  under  "uterus 
and  adnexa"  (abdominal),  or  under  "female  genitals"  (not  abdom- 
inal) .^  I  prefer  to  class  malpositions  of  the  uterus  under  "female 
genitals,"  because  in  my  opinion  they  are  not  truly  abdominal  con- 
ditions. As  to  their  pathology  I  am  also  somewhat  uncertain.  They 
certainly  are  not  new  growths  or  inflammatory  conditions,  nor  am 
I  satisfied  that  they  are  clearly  congenital  or  clearly  traumatic.  I 
therefore  leave  them  in  the  "unclassified"  division.  Scientific  knowl- 
edge has  not  yet  shown  me  whether  they  are  congenital  or  traumatic. 

Spasms,  such  as  pylorospasm  and  cardiospasm,  are  put  under 
the  "unclassified"  of  their  respective  anatomic  regions.  Spasms, 
hypertrophies,  atrophies,  dilatations,  and  functional  disturbances 
of  organs  not  known  to  be  caused  by  definite  pathologic  conditions, 
I  place  under  unclassified  of  the  special  anatomic  regions.  These 
are  not  clearly  pathologic  conditions,  and  yet  they  are  more  than 
symptoms  such  as  epistaxis,  hematemesis,  jaundice,  intestinal  ob- 
struction, ascites,  edema  of  legs. 

80 


The  question  of  symptoms  is  a  puzzling  one.  Shall  we  consider 
trifacial  neuralgia,  epilepsy,  diabetes,  as  true  pathologic  conditions? 
As  our  chart  subdivides  only  pathologic  and  anatomic  conditions,  we 
do  not  wish  to  use  it  for  symptoms.  If  trifacial  neuralgia  is  a  pain 
in  the  fifth  nerve,  it  is  merely  a  symptom,  and  we  do  not  want  to 
use  it;  but  if  it  is  a  "chronic  inflammatory"  condition  of  the  nerve, 
as  I  believe  it  is,  it  is  a  pathologic  condition,  and  we  want  to  include 
it.  Modern  medicine  is  continually  fighting  a  battle  to  teach  people 
the  difference  between  treating  symptoms  and  pathologic  conditions. 

Yet  the  most  learned  of  us  scarcely  know,  ourselves.  Which  is 
epilepsy .''  To  my  mind  it  is  a  symptom,  yet  it  appears  in  most  lists 
of  pathologic  conditions.  I  have  classified  it  as  "unclassified  of  the 
brain,"  because  I  believe  it  is  in  most  cases  due  to  a  pathologic 
condition  of  the  brain.  In  other  words,  being  in  doubt,  I  have  ac- 
cepted it — perhaps  I  am  wrong;  any  time  that  I  am  convinced  of 
it  I  can  change  it.  If  a  case  proves  to  be  due  to  a  glioma,  it  could 
be  put  under  "benign  or  malignant"  conditions,  according  to  our 
view  of  the  pathogenicity  of  glioma. 

Is  diabetes  a  symptom  or  a  pathologic  condition  ?  A  person  may 
have  sugar  in  the  urine  without  diabetes,  and  vice  versa.  Yet  to 
most  of  us  the  symptom,  sugar  in  the  urine,  means  diabetes,  and 
vice  versa.  I  shall  therefore  classify  diabetes  (sugar  in  the  urine) 
as  an  "unclassified  condition  of  the  urinary  organs."  If  in  a  given 
case  diabetes  were  proved  due  to  cancer  of  the  pancreas,  I  should 
classify  it  under  "malignant  of  the  pancreas."  But  science  has  not 
yet  taught  us  enough  about  the  pathology  of  diabetes  to  classify  all 
cases. 

The  use  of  this  chart  is  a  good  exercise  in  clear  thinking  and  in 
teaching  the  fundamentals  of  medical  knowledge  to  students. 

Personally,  I  want  it  as  an  index  to  my  cases,  so  that  I  can  tell 
whether  I  have  a  staff  of  colleagues  and  assistants  who  are  compe- 
tent to  prevent  pathologic  conditions  from  causing  symptoms. 

Certain  conditions  may  be  traumatic  in  origin,  and  yet  of  im- 
portance, because  of  the  chronic  inflammation  they  cause.  A  sub- 
acromial bursitis  is  usually  of  traumatic  origin,  yet  the  trauma  may 
be  trivial  and  the  chronic  inflammation  excessive.  I  think  it  is  best 
to  classify  such  conditions  only  as  "chronic  inflammatory,"  and  yet 
I  see  no  objection  to  listing  them  as  both.  The  chart  should  not  be 
unnecessarily  duplicated,  but  certainly,  when  used  as  an  index,  such 
duplication  is  useful ;  and  when  used  for  rough  statistics,  such  cases 
should  be  included  under  "trauma  of  the  supraspinatus  tendon,"  as 
well  as  under  "chronic  inflammation  of  the  bursa"  which  the  rupture 
causes.  In  the  previous  report  I  should  not  have  included  them  both 
under  bursitis,  but  should  have  had  the  traumatic  part  apply  to  the 
supraspinatus  tendon,  and  included  it  under  "traumatic"  of  the  un- 
classified extremities.  That  is,  rupture  of  the  supraspinatus  tendon 
is  one  pathologic  entity,  and  subacromial  bursitis  caused  by  it  is 
another.    One  may  occur  without  the  other.    Yet  they  usually  occur 

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together,  so  statistically  they  should  each  count  in  adding  one  to  the 
lists  of  chronic  inflammatory  conditions  and  traumatic  conditions, 
respectively.  But  they  occur  in  only  one  patient,  person,  or  case, 
and  cannot  appear  as  two  in  statistics  relating  to  persons,  patients, 
cases,  or  cures. 

It  must  never  be  forgotten  that  these  charts  and  tables  are  only 
a  convenient  means  for  diiferent  ends — that  is:  (1)  indices,  (2)  gen- 
eral or  detailed  statistics;  (3)  efficiency,  and  (4)  scientific  studies. 
Multiple  pathologic  or  anatomic  lesions  of  the  same  region,  or 
different  pathologic  or  anatomic  varieties  of  lesions  which  occur 
in  the  same  case,  must  be  arranged,  subtracted,  or  added,  accord- 
ing to  the  purpose  for  which  the  study  is  made,  by  verifying  all 
details  from  the  original  records.  I  merely  claim  that  these  charts 
and  tables  are  a  simpler,  surer,  cheaper,  and  more  scientific  and 
accurate  method  than  the  usual  card  catalogues  or  lists  of  names, 
which  are  mere  jumbled  collections  of  anatomic,  regional,  functional, 
systemic,  and  arbitrary  conditions  of  a  mixed  nature. 

Hydrocele  I  consider  a  "chronic  inflammatory  condition  of  the 
male  genitals,"  unless  it  is  clearly  congenital. 

Fistulas  are  classed  as  "traumatic  conditions"  of  the  organ 
concerned. 

Abdominal  adhesions  I  class  as  "chronic  inflammatory"  or 
"congenital,"  according  to  my  opinion, — lacking  exact  knowledge. 

Intestinal  obstruction.  Is  intestinal  obstruction  a  symptom  or 
a  pathologic  condition?  Cases  105  and  155  are  examples.  In 
Case  105  the  obstruction  was  due  to  a  intussusception  caused  by  a 
Meckel's  diverticulum.  Here  was  a  congenital  condition  leading 
to  a  traumatic  condition  which  produced  the  pathologic  condition 
of  intestinal  obstruction.  In  Case  155  the  obstruction  was  due  to 
volvulus  of  a  congenitally  abnormal  cecum,  —  the  volvulus  might 
be  considered  "traumatic,"  or  even  "inflammatory,"  because  the 
adhesion  of  the  appendix  to  the  left  costal  border  was  an  important 
factor  in  permitting  the  volvulus  to  occur.  Cases  53,  68,  110,  237, 
258,  269  had  cancer  of  the  intestine  or  rectum  as  the  primary  cause. 
It  would  seem  hardly  fair  to  exclude  an  important  surgical  condi- 
tion such  as  intestinal  obstruction  from  a  pathologic  classification 
on  the  ground  that  it  is  merely  a  symptom,  and  I  have  therefore 
placed  these  cases  under  "unclassified  conditions  of  the  intestine," 
and  also  placed  each  under  the  appropriate  heading  for  its  primary 
cause  or  causes. 

Extrauterine  pregnancy  I  place  as  a  "traumatic  condition  of  the 
uterus  and  adnexa." 

Banti's  disease,  splenic  anemia,  Hodgkin's  disease,  etc.,  I  con- 
sider as  "unclassified  of  unclassified,"  unless  some  local  condition 
is  the  chief  manifestation,  in  which  case  I  add  it  also  under  the  local 
region  as  "unclassified"  (for  example,  an  enlarged  spleen). 

A  septic  pilonidal  sinus  is  practically  an  "acute  inflammatory 
condition  of  the  lower  portion  of  the  back,"  although  it  is  primarily 
a  congenital  lesion.     I  class  it  under  both. 

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Hemorrhoids,  varicose  veins,  pelvic  phleboliths,  variocele,  etc., 
are  not  new  growths,  inflammatory,  congenital,  or  strictly  traumatic 
conditions.    I  consider  them  as  "unclassified." 

Neurasthenia  I  class  as  "unclassified  of  unclassified,"  although 
I  think  it  is  really  a  symptom  of  visceral  anomalies. 

Insufficiency  (uterine),  atony  (of  stomach),  I  place  under 
"unclassified"  of  the  organ  concerned. 

Hydronephrosis  I  place  under  "unclassified  of  the  urinary 
organs,"  and  add  the  pathologic  cause,  if  known  (as  aberrent 
vessel),  under  its  appropriate  heading. 

Ptosis,  Lane's  kink,  Jackson's  veil,  are  unclassified  conditions 
of  the  "unclassified  abdomen."  I  do  not  feel  at  all  sure  whether 
they  are  "congenital"  or  "traumatic." 

Concretions,  such  as  gallstones,  I  class  as  "chronic  inflamma- 
tory" conditions  of  the  containing  organ. 

Organic  heart  disease  is  considered  "chronic  inflammatory," 
unless  surely  syphilitic. 

Prolapsed  ovaries  are  considered  "unclassified  of  the  uterus 
and  adnexa." 

Perinephritic  abscess  I  class  as  "acute  inflammatory  of  the 
urinary  organs,"  as  its  origin  is  usually  from  the  kidney.  But 
if  it  were  known  to  be  from  another  cause,  I  should  classify  it 
accordingly. 

Cystic  disease  of  the  cervix  is  classed  under  "inflammatory 
conditions." 

Prolapsed  uterus,  lacerations  of  the  cervix  and  perineum,  are 
classed  as  "traumatic  of  the  female  genitals." 

The  border  line  between  uterine  conditions  classed  as  "uterus 
and  adnexa"  (abdominal),  and  uterine  conditions  to  be  classed  as 
"female  genitals"  (extra-abdominal),  is  necessarily  rather  indefinite. 

Intrauterine  tumors  (polyps),  hydramnios,  pregnancy  and  its 
complications,  appear  under  "female  genitals";  while  fibroids  and 
other  tumors  in  the  uterine  wall  appear  as  "uterus  and  adnexa," 
since  they  are  practically  abdominal.  Cancer  of  the  cervix  is  under 
"female  genitals,"  and  when  in  the  body  of  the  uterus,  as  "uterus 
and  adnexa,"  unless  it  evidently  arose  in  the  cervix  (when  in  doubt, 
it  may  be  classed  under  both  headings). 

Floating  kidney  is  classed  as  a  "congenital  condition  of  the 
urinary  organs."  It  would  be  a  matter  of  opinion  as  to  whether 
to  class  this  as  "traumatic"  or  "congenital"  or  "unclassified."  If 
science  had  yet  taught  us  to  be  exact,  we  might  place  this  condition 
under  the  right  heading. 

Diverticuli  of  the  intestine  or  bladder  are  also  in  my  opinion 
usually  "congenital,"  although  they  are  considered  by  many  writers 
to  be  traumatic. 

Mixed  tumors  of  the  parotid  gland.  There  are  certain  new 
growths  which  science  has  not  yet  been  able  to  decide  to  class  as 
benign   or   malignant.      In    fact,   some   tumors   may   be    potentially 

83 


benign  or  malignant,  and  we  cannot  by  histologic  examination  tell 
the  difference.  I  have  classed  mixed  tumors  of  the  parotid  as 
"benign,"  although  pathologists  have  called  them  by  every  conceiv- 
able pathologic  term,  including  cancer  and  sarcoma.  It  is  possible 
that  the  End  Result  Reports  of  my  ov?n  cases  will  in  time  cause  me 
to  change  my  mind. 

On  the  chart  which  I  issued  before,  I  used  the  symbol  -M  to 
indicate  multiple  conditions.  I  continue  to  do  this  for  my  personal 
convenience,  but  I  should  not  recommend  it  for  use  on  a  standard 
chart  to  be  adopted  by  all  hospitals,  because  it  causes  more  con- 
fusion than  is  justified  by  the  additional  information  for  which  it 
acts  as  an  index. 

In  these  tables  all  pathologic  diagnoses  mentioned  in  the  text 
have  been  classified,  whether  operated  upon  at  this  or  at  some  other 
institution,  or  not  operated  on  at  all.  If  any  great  Medical  Society 
should  adopt  a  standard  chart  or  classification,  they  might  rule  that 
no  case  should  be  included  unless  an  attempt  were  made  to  remove 
or  relieve  the  symptoms  caused  by  each  pathologic  condition.  They 
would  limit  the  scope  of  the  index  just  as  one  limits  the  scope  of 
the  index  in  a  book. 

In  certain  cases  where  the  disease  involves  two  distinct  organs 
or  divisions  of  one  organ,  it  has  seemed  to  me  best  to  place  them 
under  both  headings.  For  instance,  cases  of  cancer  at  the  recto- 
sigmoidal  junction  will  be  found  both  under  cancer  of  the  rectum 
and  under  cancer  of  the  intestine. 

It  is  timely  to  repeat  here  that  the  chart  should  never  be  used 
as  a  final  statement;  it  is  merely  a  convenient  index  to  refer  one  to 
the  detailed  records  of  groups  of  cases.  An  important  statement 
should  be  made  only  after  examination  of  the  detailed  record;  but 
for  many  practical  purposes,  the  rough  numbers  obtained  by  the 
addition  of  the  various  columns  will  be  sufficiently  accurate  for  use. 
For  instance,  the  total  of  our  malignant  column  means  that  we  have 
seen  at  least  94  malignant  conditions  of  different  organs,  and  by 
crossing  out  duplicate  numbers  we  find  that  these  occurred  in  only 
66  patients. 

If  the  reader  will  try  a  few  concrete  examples  from  his  own 
cases,  he  will  soon  see  the  educational  value  of  these  charts.  He 
will  find  how  indefinite  his  own  pathologic  knowledge  is ;  how  fre- 
quently he  has  to  deal  with  several  pathologic  conditions  in  his 
patients ;  how  often  he  runs  across  definite  pathologic  conditions 
which  have  no  definite  name,  and  vice  versa;  how  the  effort  to  define 
raises  interesting  pathologic  problems  and  questions ;  and  above  all, 
how  hopeful  is  the  fact  that  we  can  now  fill  out  part  of  the  chart, 
even  if  we  have  infinite  new  fields  to  conquer  in  the  infinite  number 
of  subdivisions  which  may  be  made. 

It  is  a  constant  pleasure  to  me  to  compare  my  chart  with  one 
made  from  the  Report  of  the  Hospital  of  the  Harvard  Medical 
School  of  China,  at  Shanghai,  which  Dr.   Carl  Hedbloom  has  so 

84 


carefully  edited.  With  that  End  Result  Report  at  the  antipodes, 
I  feel  encouraged  to  think  that  here  and  there  (between  Boston  and 
China — both  ways)  others  may  see  my  meaning. 

Working  for  This  Generation  or  for  The  Next 

No  matter  what  pessimists  may  say  about  human  nature,  there 
is  certainlj'  a  little  tendency  in  every  human  being  to  wish  to  be  of 
service.  This  fact  must  be  acknowledged,  no  matter  what  motives 
are  assigned  to  the  individual  instance, — whether  the  example  be 
the  statesman  devoted  to  his  country,  the  football  player  to  his  team, 
the  scientist  to  the  demonstration  of  his  theory,  the  old  maid  to  her 
sentimental  charity,  or  the  reformer  to  ideals  impracticable  until  a 
generation  or  two  hence.  All  are  selfish  and  become  unselfish.  The 
statesman  sacrifices  himself  for  his  policy  for  his  country,  and  the 
reformer  for  what  he  wishes  the  next  generation  to  be  or  to  do. 
So  it  is  with  all  forms  of  service  or  the  tendency  in  humanity  for 
the  individual  to  wish  to  be  of  service  for  the  general  good.  In  other 
words,  this  is  the  hereditary  social  instinct  of  the  individual,  and 
it  seeks  satisfaction  as  surely  as  the  bodily  functions.  We  must 
acknowledge  it  in  order  to  be  normal. 

Selfishness  and  unselfishness  differ  merely  in  the  time-return 
of  the  reward. 

The  man  whom  some  call  selfish,  demands  immediate  reward 
for  his  labor;  he  works  for  this  generation  and  is  paid  by  it.  The 
man  who  may  be  called  unselfish,  works  for  the  next  generation, 
and  necessarily  cannot  be  paid  by  it, — except  in  honor,  which  is 
often  misplaced.  The  man  who  works  for  this  generation  is  the 
practical,  successful,  beloved  person  who  backs  up  his  friends  and 
fights  their  enemies.  The  man  who  works  for  the  next  generation 
is  the  dreaming,  unsuccessful,  often  embittered  person,  who  fights 
the  faults  in  his  friends  and  backs  up  the  virtues  of  their  enemies. 

Some  persons  honor  as  unselfish  the  man  with  tact  enough  to 
make  no  enemies,  and  who  values  the  love  of  this  generation  more 
than  the  honor  of  the  next.  Others  regard  that  man  as  unselfish 
who  seeks  truth  so  sternly,  that  he  will  not  permit  a  lie  which  will 
damage  the  next  generation,  to  exist,  even  among  his  friends  in  this 
generation. 

What  is  the  point  of  all  this  in  regard  to  hospital  work?  Let 
us  transform  the  question: 

Who  is  to  pay  the  clinical  investigator  who  devotes  his  energy 
to  studying  the  scientific  side  of  medicine  and  surgery,  and  neces- 
sarily must  neglect  his  private  practice  ?  This  generation  is  perfectly 
ready  to  pay  for  his  direct  clinical  care,  which  is  worth  but  little 
more  than  that  of  any  of  his  colleagues ;  but  the  next  generation 
will  not  pay  him  for  the  formulation  of  some  clinical  law  or  principle 
which  may  be  of  infinite  service  to  all  mankind.  It  will  be  the 
practical  man  of  the  next  generation  who  will  reap  his  reward, — 
just  as  today  surgeons  all  over  this  country  are  receiving  high  fees 

85 


for   the   simple  operation   of   appendectomy   which   Reginald   Fitz, 
Alfred  Worcester,  John  Homans,  and  other  pioneers  made  possible. 

The  fact  is,  that  it  takes  about  a  generation  for  a  clinical  dis- 
covery to  become  general  knowledge.  For  instance,  Moynihan's 
demonstration  of  the  frequency  of  duodenal  ulcer,  and  of  its  ready 
cure  by  gastroenterostomy,  has  taken  twenty  years  to  be  diffused 
into  general  use.  With  minor  discoveries  pushed  with  less  energy 
by  less  able  apostles,  it  takes  much  longer.  Some  are  even  buried 
for  years  before  the  world  has  the  use  of  them.  The  truth  seeker 
for  the  next  generation  must  constantly  see  his  less  thoughtful  col- 
leagues rewarded  for  practical  service  to  this  generation,  and  must 
face  the  traditional  fate  of  the  prophet,  and  live  without  honor  in 
his  own  country. 

What  can  the  hospitals  and  End  Result  System  do  to  mitigate 
this  evil? 

Endowed  institutions  may  be  a  bridge  between  this  generation 
and  the  next.  By  the  End  Result  System  they  may  defend  the 
prophets,  and  advertise  their  new  discoveries  and  improved  methods 
to  the  world.  It  is  the  lack  of  advertisement  which  prevents  the 
spread  of  new  clinical  discoveries,  for  advertisement  in  the  true  sense 
means  the  diffusion  of  knowledge  of  facts. 

I  look  forward  to  the  day  when  endowed  institutions,  by  the 
publication  of  their  clinical  results,  will  perform  a  part  of  their 
duty  to  their  communities  in  letting  people  know  what  physicians 
and  surgeons  have  proved  themselves  competent  to  cure  or  relieve 
every  pathologic  condition,  and  just  which  surgeons  and  physicians 
are  devoting  themselves  to  the  study  of  each  incurable  condition. 

The  End  Result  System  will  give  Trustees  the  means  to  do  this, 
and  it  will  establish  definite  Standards,  so  that  each  pioneer  can 
demonstrate  that  his  added  knowledge  actually  enables  him  to 
relieve  cases  which  others  have  not  relieved.  Trustees  can  say  to 
the  man  who  has  original  ability:  "Here  is  a  class  of  cases  which 
has  hitherto  been  unsatisfactory  in  its  results.  Study  the  pathology 
and  natural  history  of  this  disease.  Devise  new  methods  of  treat- 
ment, and  if  you  have  conviction  that  the  knowledge  you  have  ac- 
quired will  enable  you  to  demonstrate  that  you  can  relieve  our 
patients  with  this  condition,  you  may  take  charge  of  them.  But  be 
sure  that  the  next  series  of  cases  clearly  excels  the  standard  we 
already  have.  If  it  does,  we  want  you  to  continue  to  treat  such  cases 
for  us ;  and  we  will  let  our  Community  and  the  Scientific  World 
know  it,  through  our  Hospital  Report." 

Most  prophets  and  pioneers  are  careless  about  their  immediate 
rewards.  This  system  would  thrust  the  reward  even  on  a  modest 
pro])het.  It  would  also  make  it  difficult  for  the  "practical  man" 
to  absorb  it.  And  it  would  make  it  worth  while  for  " practial"  men 
to  be  prophets! 

The  Endowed  Institution  would  therefore  bridge  the  generations, 
reward  prophets  in  this  instead  of  the  next  generation,  and  con- 

86 


stantly  serve  the  public  with  discoveries  of  this  generation,  instead 
of  with  the  Fads  of  this  and  the  Errors  of  the  last. 

The  Trustees  of  Endowed  Institutions  are  usually  appointed 
because  they  themselves  are  practical  successes  in  this  generation. 
Their  habits  of  life  and  of  thought  are  for  the  praise,  love,  and 
reward  of  this  generation.  They  are  in  the  habit,  in  their  businesses, 
of  looking  toward  success,  even  at  the  expense  of  a  little  truth  now 
and  then.  When  they  handle  an  Endowed  Institution,  it  is  difficult 
for  them  to  realize  that  they  are  working  for  the  next  generation, 
when  the  little  truths  of  this  generation  will  have  grown  large  and 
the  unearned  success  of  this  will  hold  the  next  generation  back. 

Examples  of  Endowed  Institutions  which  permit  graft,  nepotism, 
favoritism,  expediency,  vainglory,  hypocrisy,  and  evasion  are  far 
worse  than  these  traits  seen  in  aggressive  business,  where  the 
temptation  is  manifest.  One  can  pardon  evasion  in  social  life,  in 
business,  in  politics,  in  fun,  in  war,  in  love;  but  in  an  Endowed 
Institution  there  seems  to  be  no  excuse  for  it.  If  such  an  institution 
cannot  spend  its  money  honestly,  what  an  example  it  must  set  to  the 
next  generation  in  teaching  the  methods  to  make  money ! 

The  excuse  for  the  individual  to  sacrifice  truth  to  expediency  is 
the  struggle  for  existence.  But  an  Endowed  Institution  has  no  such 
excuse.  Better  that  it  perish  and  let  the  Truth  survive,  than  try 
to  maintain  its  own  existence  by  using  a  lie.  The  lie  may  have  been 
developed  in  the  individual  by  heredity,  but  the  Endowed  Institution 
is  a  new  being,  with  but  a  few  hundred  years  of  ancestry.  It  is  the 
expression  of  the  hope  of  those  individuals  who  have  lied  and  accu- 
mulated, that  their  money  may  be  used  to  prevent  the  need  for  lies 
in  the  struggles  of  future  generations. 

How  it  must  annoy  the  dead  benefactors  (whether  good  or  bad) 
of  our  institutions  to  see  their  Trustees  sacrifice  any  tiny  bit  of 
Eternal  Truth  for  temporary  reputation  in  the  Present  Generation ! 
From  their  timeless  point  of  view,  how  clear  it  must  seem  that  Truth 
Evaded  means  the  postponement  of  its  use  for  human  happiness. 

The  Ownership  of  Hospital  Cases 

The  Staffs  in  most  Charitable  Hospitals  consider  that  "the  use 
of  the  material"  is  their  prerogative. 

A  Junior  member  who  cares  to  study,  investigate,  or  report  on 
the  cases  that  a  Staff  Surgeon  has  operated  on,  is  supposed  to  be 
asking  a  favor.  One  often  sees  the  expression,  "I  am  indebted 
to  Dr.  So-and-So  for  the  privilege  of  studying  these  cases."  Such 
phrases  should  be  reversed,  —  "Old  Dr.  So-and-So  is,  or  should  be, 
very  grateful  to  young  Dr.  So-and-So  for  studying  these  cases." 
It  is  a  privilege  to  have  them  studied,  not  to  study  them. 

And  did  the  cases  belong  to  old  Dr.  So-and-So,  anyhow  .f*  Do 
the  cases  belong  to  the  Chief  of  Service,  to  the  Trustees,  to  the 
Hospital,  to  themselves,  or  to  the  Community.'' 

87 


Mj  idea  is  that  the  Hospital  is  a  place  for  mutual  help.  The 
Patient,  tlie  Student,  the  Professor,  the  Chief  of  Service,  the  Trus- 
tee, the  Hospital,  the  Community,  and  World-wide  Medical  Science 
— each  are  part  owners  of  "the  case."  We  must  all  be  willing  to 
learn  from,  to  teach  from,  to  study,  to  organize  to  aid,  to  be  trusted 
by,  to  contribute  to,  to  record,  and  to  analyze  each  "case"  and  all 
"cases."  The  State  of  Massachusetts  has  an  interest  in  the  cases 
in  our  Charitable  Hospitals ;  she  contributes  to  them,  and  statistics 
and  scientific  observations  which  may  be  of  future  value  to  her 
taxpayers  should  be  returned  to  her.  Medical  Science  has  an  interest 
in  every  case,  especially  those  relieved,  for  she  has  instructed  every 
Doctor,  Student,  or  Nurse  who  helped  care  for  the  Patient.  The 
"case"  owes  her  everything  it  can  give  in  return.  In  the  same  way 
the  "case"  owes  to  the  Student  what  the  Patient  has  received  from 
the  Professor,  the  Chief  Surgeon,  or  Physician. 

Who,  then,  owns  the  case.''  Why  should  the  Investigator,  who 
studies  the  case  so  as  to  formulate  some  general  principle  which 
may  help  other  cases,  thank  the  Chief  or  the  Professor  or  the 
Trustee.''  Is  the  man  who  is  capable  of  logical  reasoning,  and  at 
the  same  time  willing  to  record  and  analyze  cases,  easier  to  find 
than  a  Trustee,  a  Professor,  or  a  Student.''  The  main  difference  is, 
that  the  man  who  records,  analyzes,  and  formulates  general  prin- 
ciples usually  receives  his  recompense  after  he  is  dead.  Few  care 
for  this  reward. 

At  this  hospital,  every  patient  is  willing  to  have  his  or  her  case 
analyzed ;  and  I,  as  Chief  of  Service,  shall  be  grateful  to  any  young 
man  who  has  the  zeal  and  ability  to  analyze  them.  Every  operation 
which  is  performed  here  is  an  experiment,  but  as  it  is  publicly  re- 
corded under  his  own  name  by  each  experimenter,  it  is  a  justifiable 
experiment.  In  this  it  differs  from  the  experiments  in  many  Chari- 
table Hospitals,  where  the  experimenters  do  not  study,  record,  and 
analyze  their  cases.  In  such  instances  the  experiments  are  per- 
formed for  the  benefit  of  the  performer,  who  becomes  a  good  oper- 
ator, a  popular  surgeon,  a  chief  of  service,  and  perhaps  allows  some 
investigator  the  privilege  of  studying  his  carelessly  conducted 
experiments. 

Trustees  should  realize  that  "the  material,"  which  means  the 
patients,  is  of  value  to  the  "operator,"  because  each  operation, 
whether  successful  or  unsuccessful  for  the  patient,  improves  the 
technique  of  the  operator.  They  should  take  the  part  of  the  thought- 
ful (even  if  clumsy)  operator,  who  studies  pathologic  conditions 
rather  than  grace  in  technique.  Such  a  man  needs  "material"  to 
become  a  good  operator;  but  no  amount  of  "material"  will  make  the 
good  operator  a  good  surgeon,  unless  he  takes  proportionate  time 
to  study  pathologic  conditions  and  follows  his  cases,  to  know  whether 
his  operations  were  appropriate  as  well  as  beautiful. 

Plenty  of  "material"  makes  a  good  operator  and  a  "successful" 
surgeon,  but  "successful"  surgeons  may  not  be  successful  in  their 

88 


results.      It  is  possible  by  the  End  Result  System  to  demonstrate  ' 
this.    The  "material"  should  be  used  to  make  good  operators  out  of 
clumsy  but  good  surgeons,  if  the  "good  operators"  will  not  use  it 
to  become  good  surgeons.    Surgery  is  more  mental  than  mechanical. 

Let  a  surgeon  in  question  have  the  choice  of  the  material,  with 
instructions  to  operate  only  on  those  cases  which  he  can  bring  to  a 
successful  issue,  and  refer  all  others  to  the  Chief  of  Service.  If  his 
pathologic  knowledge,  diagnostic  ability,  skill,  care,  and  judgment 
cannot  be  tested  in  this  way,  then  it  is  useless  to  keep  baseball 
averages. 

Would  the  patients  be  worse  off?  Would  you  prefer  to  be 
assigned  to  this  surgeon,  under  these  conditions;  or,  as  you  would 
be  at  present,  merely  by  the  ward.'' 

Rare  Cases 

Among  the  337  cases  here  recorded  are  the  following  unique, 
rare,  or  unusually  interesting  cases : 

Case  8.    Renal  colic  as  the  first  symptom  of  Banti's  disease. 

Case  24.    Chronic  pneumococcus  infection,  with  multiple  arthritis  and  mem- 
branous pneumococcus  gastritis. 

Case  33.    Distention  of  the  common  bile  duct,  which  contained  30  oz.   Re- 
covery. 

Case  34.    A  pilonidal  (?)  sinus  on  the  anterior  margin  of  the  rectum. 

Case  42.    Primary  cancer  of  the  Fallopian  tube. 

Case  63.    Tuberculous  strictures  of  the  intestine,  followed  later  by  cancerous 
strictures  of  the  intestine. 

Case  86.    Chronic  bronchiectasis  causing(?)  acute  brain  abscess. 

Case  105.    Intussusception — Meckel's  diverticulum. 

Case  110.    Recovery  from  cancer  which  involved  3  separate  portions  of  the 
intestine  and  abdominal  wall. 

Case  114.    Microscopic  cancer(?)  in  a  fibrous  breast. 

Case  142.    Salivary  calculus. 

Case  155.    Volvulus  of  the  cecum,  with  appendix  attached  to  the  left  costal 
margin. 

Case  188.    Acute  pancreatitis  (?). 

Case  197.    Cj'stic  lymphoma  of  neck. 

Case  221.    Buckling  of  tlie  edge  of  the  liver. 

Case  228.    Acute  hemorrhagic  cystitis  (colon  bacillus),  without  trauma,  pain, 
or  instrumentation.    Complete  recovery. 

Case   224.     Retroperitoneal   abscess,   simulating  malignant  disease   of  the 
pancreas. 

Case  229.    Extreme  case  of  elephantiasis  of  the  legs,  with  recovery. 

Cases  230,  232.    Operable(?)  cancer  of  the  head  of  the  pancreas. 

Case  233.    Congenital  malformation  of  the  spine,  etc. 

Case  237.    Multiple  adenomata  of  the  intestine,  with  malignant  change  in 
one  and  metastases  to  both  ovaries. 

Case  244.    Cold  abscess  of  the  back,  containing  bone  and  staphylococcus 
aureus.    No  known  origin. 

Case  247.    Perinephritis  without  suppuration. 

Case  250.    Torsion  of  appendices  epiploicae. 

Case  252.    Adamantinoma  of  the  jaw. 

Case  257.    Osteochondroma  involving  upper  half  of  humerus,  excised  with- 
out nerve  or  muscle  injury. 

Case  259.    Calcified  lipoma  arborescens  of  knee. 

89 


Case  270.  Colloid  carcinoma  of  the  ovary.  Recovery  in  spite  of  peritoneal 
involvement. 

Case  279.    Recovery  after  transfusion  between  Groups  2  and  4. 

Case  284.  Adenoniyoina(?)  in  old  appendix  scar,  without  primary  uterine 
tumor. 

Case  295.    Torsion  of  omentum  simulating  acute  appendicitis. 

Case  304.    Dilatation  of  seminal  vesicle  without  infection. 

Case  308.  Psanmio-carcinoma  of  ovary,  with  cancerous  peritonitis.  Inoper- 
able.   Apparent  recovery  from  radium  applications. 

Case  314.  Intravesical  cyst  of  ureter.  Bacteriuria  followed  by  formation  of 
renal  stone  years  after  relief  of  obstruction. 

Case  318.    Chronic  abscess  of  tongue  simulating  cancer. 

Case  321.  Complete  rupture  of  supraspinatus  tendon.  (Common,  but  not 
widely  known  or  operated  on.) 

These  cases  are  so  exceptional,  that  it  would  be  of  almost  vital 
interest  to  any  patient  having  any  one  of  them  to  learn  how  a  similar 
case  was  treated,  and  how  it  resulted.  So  it  would  be  for  the  family 
physician  of  any  patient  who  had  any  one  of  these  diseases. 

Probably  most  family  physicians  and  many  surgeons  do  not  even 
know  the  names  of  many  of  these  conditions,  and  it  is  very  unlikely 
that  any  one  physician  knows  the  names,  symptoms,  and  usual 
outcome  of  all  of  them.  He  would  not  even  know  where  to  look  for 
them  in  a  medical  library. 

Now  if  over  10  per  cent  of  my  cases  have  been  these  rare  con- 
ditions, must  there  not  be  as  large  a  proportion  in  our  Charitable 
Hospitals?  Would  their  outcome  not  be  of  vital  interest  to  the 
patients  who  have  similar  ones,  and  to  the  physicians  who  have 
charge  of  them?  Must  they  not  occur  in  about  the  same  ratio  in 
private  practice,  too?  Your  own  case,  reader,  may  be  one  of  them. 
Will  you  select  the  doctor  to  treat  it,  because  he  is  assigned  to  your 
ward,  because  he  is  old,  because  he  is  popular,  or  because  he  is  a 
friend  or  relative? 

Do  you  realize  that  the  Seniority  System  in  our  hospitals  prac- 
tically prohibits  any  energetic  young  man  (without  a  private  for- 
tune) from  taking  the  time  to  study  and  analyze  such  cases,  and 
that  it  also  prohibits  the  man  with  a  private  fortune  from  operating 
on  such  cases,  even  if  he  does  study  and  analyze  them,  and  is  ready 
to  prove  he  can  help  them?  Every  day  he  puts  on  such  study,  puts 
him  farther  beliind  in  private  practice  and  no  farther  ahead  at  the 
hospital. 

At  this  hospital,  I  propose  to  keep  track  of  the  work  of  every 
young  doctor  in  this  community;  and  if  he  writes  a  good  paper  on 
the  analysis  of  any  rare  group  of  cases,  and  thus  proves  that  he  is 
conversant  with  their  pathology  and  the  natural  history  of  their 
usual  progress,  I  shall  call  him  in  consultation  on  future  similar 
cases. 

Routine  Cases 

The  bulk  of  the  cases  in  this  Report  are  Routine  Cases  — 
Hernias,  Uterine  Fibroids,  Cancers  and  Cysts  of  the  Breast,  Appen- 
dicitis cases,  etc.     The  science  of  surgery  developed  by  the  last 

90 


generation  has  enabled  us  to  treat  such  cases  satisfactorily.  It  is 
for  such  cases  that  the  brilliant  operators  are  charging  high  prices. 
They  are  reaping  the  harvest  that  was  sown  by  the  student  pioneers 
of  the  last  generation.  These  pioneers  did  their  service  for  mankind, 
not  for  the  less  studious  members  of  the  surgical  profession.  They 
hoped  that  the  price  of  operations,  which  they  studied  to  make  safe 
and  easy,  would  go  down,  so  that  mankind,  not  the  surgeons  of  the 
day,  would  benefit. 

The  Seniority  System  at  our  hospitals  keeps  the  price  of  routine 
operations  up,  so  that  the  community  does  not  get  the  legacy  the 
pioneers  left  them  in  their  wills.  And  the  Seniority  System  prevents 
the  young  pioneers  of  today  from  getting  a  fair  share  of  their  own 
harvest. 

At  this  hospital  we  have  done,  and  can  do,  routine  operations 
just  as  successfully  as  the  brilliant  operators,  and  we  only  ask 
payment  for  our  actual  work.  Why  pay  a  high  price  for  speed  of 
production  of  an  unstandardized  article,  when  you  can  obtain  at  a 
reasonable  price  a  guaranteed  standard  article.'' 

Standards 

The  exponents  of  scientific  management  constantly  tell  us  that 
standards  are  necessary,  if  we  wish  to  attain  efficiency. 

Is  it  possible  to  standardize  the  treatment  of  disease,  or  the  work 
of  hospitals,  or  the  work  of  individual  members  of  hospital  staffs.-* 
Is  it  possible  to  standardize  knowledge,  skill,  judgment,  and  diag- 
nosis, or  curable  and  incurable  diseases,  calamities,  and  mortality? 
Is  it  possible  that  we  can  have  standards  for  cases  like  appendicitis, 
cleft  palate,  pneumonia,  hernia,  and  fibroids  of  the  uterus  ? 

It  is  the  opinion  of  the  writer  that  such  standards  can  be  estab- 
lished, and  one  of  the  aims  of  this  hospital  is  to  establish  standards ; 
even  with  the  few  cases  we  have  already  had,  we  can  in  a  measure 
set  up  standards,  because  no  such  standards  of  consecutive  opera- 
tions have  heretofore  been  offered.  It  is  not  customary  in  hospital 
work  to  set  standards;  there  is  nothing  to  go  by,  to  determine 
whether  the  work  of  a  given  hospital  is  efficient  or  not.  Other  hos- 
pitals have  not  yet  recognized  that  if  they  wish  to  send  practitioners 
into  the  community  who  will  treat  only  the  cases  they  are  competent 
to  treat,  they  must  begin  by  example  in  the  hospitals  themselves. 
For  instance,  the  standard  of  an  ideal  local  hospital  would  be  to 
accept  no  cases  which  it  cannot  cure  or  relieve,  unless  that  hospital 
is  an  investigating  and  teaching  hospital  which  honors  the  members 
of  its  staff,  because  of  their  demonstrated  ability  to  treat  the  diffi- 
cult cases  which  are  discarded  by  minor  hospitals.  This  hospital, 
for  instance,  freely  acknowledges  and  admits  that  the  surgeons 
appointed  by  the  trustees  of  the  large  hospitals  in  Boston  should 
be  the  best — so  why  should  it  accept  for  treatment  the  difficult  or 
dangerous  cases  .-^  We  can  always  obtain  the  services  of  these 
staff  surgeons   for  either  our  rich  cases  or  our  poor  cases.    They 

91 


may  treat  the  poor  cases  at  their  hospitals,  and  the  rich  ones 
at  their  homes  or  in  private  hospitals.  We  have  no  obligation  to 
accept  cases  which  we  cannot  diagnose,  or  those  which  we  are  not 
qualified  to  treat.  Is  there  any  suburban  hospital  which  makes  an 
effort  to  establish  such  a  standard  as  this?  Is  there  any  other  hos- 
pital which  is  willing  to  admit  that  it  is  second  class,  and  sets  its 
price  according  to  its  standard  rather  than  according  to  the  wealth 
of  the  patient? 

Is  there  a  standard  of  judgment?  (See  page  99.)  Our  standard 
of  judgment  is  demonstrated  in  so  far  as  we  succeed  in  not  attempt- 
ing anything  which  we  cannot  bring  to  a  successful  issue.  Is  it  not 
possible  to  put  the  same  test  into  a  large  hospital  by  assigning  a 
ward  to  a  junior  surgeon,  with  instructions  to  refer  all  cases  which 
he  cannot  relieve  to  another  ward,  under  the  charge  of  a  senior 
surgeon  whose  judgment  had  been  demonstrated  by  years  of  a 
similar  test?  The  junior  surgeon  who  was  successful  in  doing  this 
would  qualify  as  having  good  judgment. 

Is  there  a  standard  of  skill?  (See  page  98.)  Our  standard 
of  skill  can  be  measured  by  the  number  of  cases  in  which  it  has  been 
proved  to  be  lacking,  compared  with  the  number  and  character  of 
cases  in  which  it  has  been  successful.  Is  it  not  possible  to  apply 
the  same  test  to  a  junior  surgeon  in  a  large  hospital? 

Are  there  standards  of  care?  Is  it  not  possible  in  other  hospitals 
to  see  whether  our  standards  of  never  having  had  a  favorable  result 
of  any  of  our  cases  prevented  by  sepsis  cannot  be  realized?  Would 
our  standards  not  have  been  even  higher,  if  all  our  cases  had  also 
been  free  from  stitcli  abscess,  hematoma,  etc.  ? 

Are  there  standards  of  curable  and  incurable  conditions?  Al- 
though this  matter  is  always  linked  closely  with  judgment,  and 
subject  to  qualification,  we  can  establish  cases  of  fibroid  tumors 
of  tlie  uterus  as  a  condition  in  every  case  of  which  the  result  should 
be  successful;  and  we  may  set  against  it  cases  of  cancer  of  the  liver 
(of  which  there  is  no  authentic  cure  reported). 

It  requires  two  different  types  of  men  to  treat  curable  and 
incurable  conditions.  Most  men  can  be  taught  to  cure  curable 
conditions,  but  very  few  can  teach  the  world  how  to  cure  incur- 
able conditions.  At  present  our  hospitals  put  no  premium  on  the 
cure  of  rare  or  difficult  cases,  even  if  an  individual  is  found  coura- 
geous enough  to  study,  investigate,  experiment,  and  eventually  teach 
the  world  liow  to  relieve  such  conditions,  which  have  been  supposed 
to  be  obstinate  or  incurable. 

Are  standards  of  results  possible?  Certainly  we  may  say  that 
interval  appendectomy  and  operations  for  simple  hernia  and  fibroids 
of  the  uterus  should  have  no  mortality  or  complications;  but  in  the 
cases  of  cancer  of  the  pancreas,  we  must  acknowledge  that  science 
has  not  yet  taught  us  to  avoid  a  large  percentage  of  mortality.  Is  it 
not  possible  to  compare  the  percentage  of  success  in  cases  of  these 
conditions  in  different  hospitals,  and  to  establish  a  minimum  stand- 

92 


ard,  so  that  a  hospital  whose  mortality  is  less  may  feel  proud,  and 
a  hospital  whose  mortality  is  greater  may  learn  from  the  experience 
of  others? 

For  the  man  who  practices  surgery,  there  are  two  kinds  of 
mortality — chance  and  intentional. 

Chance  mortality  is  the  kind  which  occurs  unexpectedly,  and 
which  no  amount  of  foresight  can  prevent.  It  is  caused  by  unantici- 
pated Calamities  or  Catastrophes.  Death  from  pulmonary  embolism 
is  a  good  example.  For  the  junior  surgeon  who  is  given  a  ward  and 
told  that  he  must  exhibit  his  judgment  by  the  selection  of  cases 
which  he  can  bring  to  a  successful  issue,  there  is  also  a  danger  of 
such  calamities.  Is  it  not  possible  to  determine  what  this  percentage 
of  danger  is,  just  as  easily  as  it  is  to  compute  a  fire  risk?  Mine,  at 
this  hospital,  is  1 — 260. 

Intentional  mortality  is  incurred  by  the  chief  surgeon  when  he 
attempts  cases  in  which  the  condition  is  acknowledged  to  be  grave. 
It  is  speculative — like  gambling  against  known  chances  in  a  game  in 
which  skill,  j  udgment,  and  luck  all  count.  Our  intentional  mortality 
is  shown  on  page  105. 

Is  there  a  standard  of  mortality  from  anaesthesia?  With  modern 
methods  there  should  be  no  anaesthetic  deaths,  unless  the  attempt 
at  anaesthesia  is  made  by  an  expert  anaesthetist.  It  is  possible  to 
give  anaesthetists,  just  as  it  is  surgeons,  a  chance  to  select  their 
cases,  and  to  bring  the  burden  of  the  dangerous  cases  on  those  who 
have  in  the  past  proved,  by  their  judgment  and  skill,  their  ability 
or  right  to  receive  this  honor. 

At  this  hospital,  by  selection  of  cases  for  local,  spinal,  intra- 
buccal,  and  gas  anaesthesia,  we  have  had  no  anaesthetic  mortality. 
When  the  cases  have  showed  a  considerable  anaesthetic  risk,  we  have 
relied  on  the  services  of  Dr.  Freeman  Allen,  Dr.  N.  N.  Morse,  and 
others;  in  uncomplicated  cases  we  have  taken  the  risk  ourselves. 
But  we  believe  that  even  when  an  expert  anaesthetist  is  engaged,  it 
only  partially  relieves  the  surgeon  of  his  responsibility, — his  selec- 
tion of  the  anaesthetist  is  just  as  much  a  part  of  his  duty  as  the 
selection  of  any  other  consultant.  When  he  relies  on  that  consult- 
ant's advice,  and  acts  on  it,  he  is  no  less  responsible  for  the  decision. 
To  rely  on  bad  judgment  is  in  itself  an  error  of  judgment.  As  to 
our  standards  for  individual  operations,  or  for  individual  pathologic 
conditions,  reference  may  be  made  to  the  table  presenting  combined 
index  and  statistics. 

Finally,  let  us  remember  that  the  object  of  having  standards 
is  to  be  sure  to  raise  them.  The  standards  which  we  are  establishing 
may  be  low  ones,  but  we  are  making  them  to  raise  them.  We  offer 
them  to  other  hospitals  for  comparison,  not  necessarily  for  emula- 
tion. It  would  be  a  pleasure  to  see  them  surpassed.  The  End  Result 
System  means  the  introduction  of  the  Comparative  Principle  into 
Clinical  Science,  and  it  means  the  use  of  the  Principles  of  Scientific 
Management  in  Hospital  Organization. 

93 


Our  Contribution  to  the  Cancer  Problem 

If  it  is  the  object  of  this  hospital  to  treat  only  cases  which  we 
can  cure  or  relieve,  what  is  to  be  our  future  relation  to  the  Cancer 
Problem?  We  feel  that  in  exploiting  the  End  Result  System,  we 
have  already  done  something  toward  it  from  the  statistical  side. 
If  all  the  hospitals  in  this  state  had  the  End  Result  System,  how 
easy  the  compilation  of  statistics  would  be.  Reference  to  our  Index 
table  shows  that  of  our  cases  the  following  have  had  this  disease: 
10,  38,  39,  41,  42,  46,  51,  53,  55,  68,  78,  79,  85,  96,  110,  114,  119, 
133,  145,  146,  148,  149,  151,  173,  185,  186,  197,  204,  218,  223,  230, 
231,  232,  237,  252,  253,  258,  261,  267,  268,  269,  270,  284,  291,  292, 
296,  298,  308,  309,  326,  327,  331,  335,  337.  Any  one  who  is  inter- 
ested can  determine  from  the  abstracts  of  these  cases  any  data  he 
wishes  for  the  particular  purpose  he  has  in  mind,  and  he  may  have 
access  to  our  detailed  records  for  further  facts  in  doubtful  cases. 
If  he  is  studying  adamantinoma  of  the  jaw  or  psammoma  of  the 
ovary,  he  can  in  a  few  minutes,  by  using  the  Index  table,  pick  out 
our  cases  to  add  to  his  own.  If  he  wishes  to  follow  up  the  broader 
problem  of  the  relative  frequency  of  the  disease  in  different  organs, 
he  can  find  it  as  readily.  A  record  of  the  mortality,  the  relative 
morbidity,  the  duration  of  life  after  operation,  month  by  month; 
variation  in  the  histologic  types ;  the  record  of  the  age,  the  sex,  or 
any  other  item  which  we  have  observed,  is  as  readily  and  rapidly 
obtained. 

If  every  hospital  in  this  Commonwealth  had  similar  abstracts 
of  its  cases  available,  and  as  simply  indexed,  how  accurately  the 
statistician  could  compute  his  statistics,  and  how  easily  his  opponent 
could  use  the  same  cases  to  confute  his  conclusions  or  to  correct  his 
errors. 

But  our  chief,  selfish  interest  in  the  cancer  problem  is  to  show 
that  we  can  select  those  cases  which  we  can  relieve,  and  those  which 
we  must  refer  to  better  qualified  surgeons,  because  the  End  Result 
would  prove  that  our  operation  in  such  cases  had  done  little  or  no 
good.  We  do  not  care  to  operate  on  cases  of  cancer  which  will  not 
have  a  respite  of  at  least  a  year  after  the  operation.  Is  it  possible 
to  select  such  cases  ? 

Hitherto  we  have  not  refused  the  chance  of  benefit  from  opera- 
tion to  any  case  that  has  come  to  us,  except  Cases  85,  268,  and  327, 
which  we  considered  absolutely  hopeless.  Cases  53,  55,  146,  and 
218  were  referred  to  more  skillful  operators  (Dr.  C.  A.  Porter  and 
Dr.  D.  F.  Jones)  ;  and  Cases  309  and  337  preferred  the  chances 
of  radium  treatment.  And  we  have  not  refused  to  admit  any  case 
which  any  other  surgeon  thought  might  he  operable.  So,  hitherto, 
we  cannot  be  said  to  have  selected  our  cases ;  but  in  the  future  we 
are  going  to  try  to  do  so. 

In  order  that  we  may  be  guided  in  the  right  direction  in  tlie 
future,  let  us  study  the  past:  Were  there  any  cases  in  which  before 
the  operation  we  would  have  given  a  bad  prognosis,  and  in  which  the 

94 


result  showed  that  we  were  wrong?    Or  were  there  cases  apparently 
of  good  prognosis  in  which  there  was  not  a  respite  of  at  least  a  year? 
Those  of  E.  A.   C.'s   cases  which  died  within  a  year  were  the 
following: 

Case  10.  Gangrenous,  melanotic  sarcoma  of  the  cheek  in  a  senile  clergyman 
of  84.    A  purely  palliative  operation,  with  healing  by  first  intention. 

Cases  145,  173.  Exploration  for  obviously  incurable  cancer  of  the  stomach, 
in  the  hope  of  performing  palliative  gastroenterostomy. 

Cases  230  and  232.  Patients  with  long-standing,  deep,  painless  jaundice  and 
distended  gall  bladders. 

Case  231.  A  case  of  large  abdominal  tumor  with  ascites,  in  which  the  diag- 
nosis of  ruptured  papillomatous  cyst  of  the  ovary  was  reasonably  clear. 

Case  269.  A  cachectic,  elderly  woman  whose  history  and  physical  examina- 
tion clearly  indicated  inoperable  cancer  of  the  rectum,  and  that  enteros- 
tomy would  prolong  her  life  only  a  few  months. 

Case  292.  A  man  with  digestive  symptoms  (blood  pressure,  220),  from 
whom  I  successfully  removed  the  pyloric  portion  of  the  stomach  for  an 
indurated  ulcer  (possibly  cancer),  and  who  died  within  the  year  from 
endocarditis. 

We  think  that  there  can  be  no  question  but  that  any  experienced 
surgeon  would  have  been  glad  to  avoid  any  of  these,  except  possibly 
the  last.  They  were  clearly  palliative  operations  only.  We  believe 
that  these  cases  answer  the  questions,  and  that  the  undoubted  benefit 
received  by  the  other  cases  proves  that  we  can,  with  a  very  small 
margin  of  error,  select  in  the  future  the  cases  which  we  can  benefit. 

We  believe  that  we  can  best  contribute  to  the  cancer  problem 
by  not  operating  on  cases  so  advanced,  that  we  think  they  will  die 
within  a  year. 

If  any  such  cases  which  we  refuse  to  accept  are  relieved  or  cured 
by  more  skillful  surgeons,  by  X-ray,  by  radium,  by  Christian  Science, 
or  by  quackery,  we  shall  most  cheerfully  place  the  credit  where  it 
is  due.  We  invite  you  to  send  patients  who  plan  to  have  such  treat- 
ment to  us,  merely  to  put  them  on  authoritative  record. 

Notice  Case  308,  which  is  an  authentic  example  of  the  efficacy 
of  radium  in  the  treatment  of  an  inoperable,  diffuse  abdominal 
cancer. 

The  various  institutions  which  are  now  specializing  on  the  treat- 
ment of  cancer  should  publish  annual  End  Result  reports  of  all  their 
cases,  so  as  to  let  the  medical  public  and  the  lay  public  know  just 
what  the  status  of  radium  treatment  is,  how  often  it  prolongs  life, 
and  how  often  burns  or  other  bad  results  follow.  The  above  case 
was  a  miracle  in  spite  of  the  burn.  Why  should  the  managements 
of  these  institutions  not  let  us  know  the  results  of  each  experiment? 
This  secrecy  breeds  distrust. 

If  every  hospital  adopted  the  End  Result  System  for  its  cancer 
cases  only,  even  if  for  the  present  no  other  classes  of  cases  were 
reported,  we  might  help  this  cancer  problem  in  a  practical  way. 

95 


Authority 

Suppose  that  after  keeping  up  these  Reports  for  several  years, 
I  should  be  able  to  prove  some  important  point  in  clinical  science. 

Would  not  my  proofs  be  considered  worthless,  because  they  lack 
authority? 

Suppose  that  a  member  of  a  Charitable  Hospital  Staff  should 
make  a  statement  of  the  same  kind.  Would  he  not  carry  the  weight 
of  the  authority  of  that  hospital.-* 

But,  would  not  his  statements  carry  more  authority,  if  the 
Trustees  of  that  hospital  issued  an  End  Result  Report  to  which 
one  could  refer  for  confirmation  (by  the  recorded  clinical  results) 
of  suspiciously  unusual  claims.'' 

I  hold  that  my  authority,  backed  by  the  End  Result  Report  of 
even  a  few  cases,  is  better  than  the  authority  of  a  member  of  the 
Staff  of  a  Charitable  Hospital  which  does  not  publish  or  have  in  its 
possession  any  such  report. 

And  as  for  "authorities"  themselves, — if  End  Result  reports 
were  in  general  use,  perhaps  some  modest  men  who  never  speak 
in  public,  nor  write  for  the  journals,  might  be  obliged  to  become 
"authorities." 

We  might  pick  for  our  consultants  men  whose  rfesults  proved 
that  they  knew  how  to  relieve  given  classes  of  cases. 

At  present,  "authorities"  are  often  made  by  position,  not  by 
having  previously  proved  their  unusual  knowledge  by  demonstration 
of  clinical  success.  And  shall  we  not  see  men  become  "specialists" 
by  demonstration  of  special  knowledge,  rather  than  men  choosing 
specialties  } 

We  recognize  as  "specialists"  only  those  who  have  proved  hy 
results  that  their  choice  of  a  specialty  has  been  followed  by  study, 
application,  industry,  and  opportunity  greater  than  ours  in  that 
particular  group  of  cases. 

Statistics  and  Experience 

Some  persons  despise  statistics.  They  quote  the  old  story  of 
lies,  damned  lies,  and  statistics.  Some  even  trust  their  individual 
experience  more  than  that  of  their  whole  race.  They  decide  whether 
they  will  have  an  operation  by  whether  their  neighbor  recovered  or 
not.  It  makes  little  difference  to  them  whether  or  not  the  operation 
was  performed  for  the  same  condition. 

We  all  have  this  tendency  to  believe  the  evidence  of  our  own 
senses  rather  than  the  evidence  deduced  from  the  recorded  experi- 
ence of  others.  In  other  words,  we  trust  our  own  senses  and  brains, 
which  have  constantly  deceived  us,  more  than  the  facts  recorded 
and  arranged  for  our  use  by  others;  and  in  any  matter  in  which 
we  lack  experience  ourselves,  we  had  rather  trust  the  senses  and 
brains  of  some  man  whom  we  know  has  had  much  personal  experi- 

96 


ence,  than  the  dry,  recorded  facts  which  have  been  analyzed  by 
some  one  who  wrote  a  book. 

And  yet  we  know  that  as  physicians  or  surgeons  we  are  indebted 
for  99  per  cent  of  our  knowledge  to  the  carefully  recorded  facts 
which  the  painstaking  pioneers  of  previous  generations  and  of  this 
generation  have  given  to  us. 

The  truth  is,  we  really  go  by  statistics  all  the  time,  in  matters 
which  are  tolerably  certain,  and  only  when  in  doubt  do  we  fall  down 
and  worship  Personal  Experience. 

It  is  our  tendency  to  be  surest  of  what  (1)  we  ourselves  have 
seen,  heard,  or  felt;  slightly  less  sure  (2)  of  what  our  friends  say 
they  have  seen,  heard,  or  felt;  somewhat  less  sure  (3)  of  what 
persons  we  don't  know  say  they  have  seen,  heard,  or  felt. 

Now,  as  every  individual  has  this  same  experience  in  relation 
to  others,  it  follows  that  we  all  are  really  more  sure  of  what  we  all 
say  we  have  experienced  than  what  any  one  of  us  says  he  has  experi- 
enced. In  other  words,  each  admits  that  the  combined  experience 
of  others  is  better  than  anybody  else's  but  his  own;  or  if  he  has  had 
little  or  none,  that  of  some  one  whom  he  substitutes  for  himself  and 
whom  he  believes  has  had  much  experience. ' 

Since  we  trust  our  own  experience  so  much,  it  is  particularly 
important  to  finish  each  experiment  we  try,  and  be  sure  that  it  is 
complete.  We  should  each  like  to  have  the  other  make  sure  of  his 
experience  before  he  advises  us  on  the  strength  of  it.  If  he,  too, 
has  experimented,  let  him  be  sure  that  he  relates  his  results  just 
as  they  were,  and  does  not  use  his  fancy. 

It  is  for  these  reasons  that  these  cases  are  reported,  and  that 
I  wish  to  see  the  End  Result  System  get  into  all  hospitals.  It  will 
prevent  my  telling  fish  stories,  and  my  friends  at  other  hospitals 
from  telling  fish  stories,  and  eventually  lead  to  Statistics  which  will 
help  everybody  in  the  world. 


If  I  can  present  such  a  Report  for  337  cases,  the  100  doctors 
of  the  Massachusetts  General  Hospital  could  give  us  a  Report  of 
33,700  cases ;  and  they  only  treat  about  6,000  ward  patients  a  year ! 


97 


ANALYSIS  OF  OUR  TOTAL  ERRORS  IN  FIVE  YEARS 
WITH  A  VIEW  TO  FUTURE  IMPROVEMENT 

It  is  the  intention  of  this  hospital  to  be  of  service  to  persons 
of  moderate  means.  We  plan  to  give  them  their  money's  vrorth  at  as 
low  a  rate  as  is  consistent  with  the  ability  of  myself,  my  colleagues, 
my  assistants,  and  my  employees  to  make  a  living.  It  is  our  inten- 
tion as  far  as  possible  to  have  no  bad  results,  and  to  make  sure  that 
every  patient  who  leaves  this  hospital  has  been  benefited  to  the 
utmost  that  skill,  care,  equipment,  judgment,  painstaking  diagnosis, 
and  intelligent  selection  of  cases  and  of  consultants  can  accomplish. 

We  believe  that  there  could  be  no  more  exquisite  test  of  a 
surgeon's  ability  than  to  put  him  in  a  position  where  he  may  operate 
on  all  hopeful  cases,  but  where  he  must  refuse  to  operate  on  those 
cases  which  he  thinks  he  may  not  relieve,  and  must  refer  to  the 
acknowledged  leaders  of  his  community  all  cases  in  which  he  dreads 
failure.  If  "the  best"  do  not  succeed,  his  judgment  will  be  vindi- 
cated; if  they  do  succeed,  he  will  convict  himself  either  of  lack  of 
skill,  judgment,  or  self-confidence.  Some  day  surgical  science  may 
reach  a  point  where  the  surgeon  will  be  willing  to  undergo  this  test, 
and  not  explain  his  failures  on  the  ground  of  the  unknown  forces 
which  we  call  impossibility  and  chance.  If  my  scientific  knowledge 
now  enables  me  to  do  this  with  less  than  2  per  cent  of  error,  surely 
in  another  generation  such  a  test  as  this  will  be  no  more  remarkable 
than  those  of  the  Civil  Service  today. 

Owing  to  the  system  observed  in  previous  Reports,  of  making 
marginal  symbols  and  of  summarizing  them  after  the  case  abstract, 
we  now  have  a  readily  available  list  of  all  our  failures  during  five 
years.  This  enables  us  to  analyze  the  total,  to  see  what  we  can  do 
about  preventing  the  occurrence  of  similar  errors ;  in  other  words, 
to  improve  our  efficiency.  The  reader  is  referred  to  previous  Reports 
for  more  detailed  analysis  of  the  symbols  in  each  case. 

^  In  the  analysis  which  we  now  undertake,  only  those  cases  that 
have  been  under  the  charge  of  E.  A.  C.  in  this  hospital  will  be  in- 
cluded. Cases  operated  upon  by  E.  A.  C.  in  other  hospitals  previous 
to  entrance  in  this  hospital,  or  since  their  discharge  from  this  hos- 
pital, will  not  be  included,  even  though  mentioned  in  the  text.  The 
detail  of  cases,  in  which  the  error  was  theoretical  or  resulted  in 
trivial  or  no  harm  to  the  patient,  will  be  omitted,  although  "Straws 
show  Avhich  way  the  wind  blows."  During  these  five  years,  five 
patients  operated  upon  by  E.  A.  C.  have  died  in  the  hospital.  These 
cases  will  be  considered  separately  on  page  105. 

Total  Errors  Due  to  Lack  of  Technical  Knowledge  or  Skill 

IN  Five  Years 
Cases  39,  80,  114,  186,  250  were  trivial.    Case  31  —  I  probably 
missed  a  small  gallstone,  but  one  of  the  Mayos  missed  the  same  one, 

'The  above  omissions  will  explain  tliose  instances  in  which  the  marginal  symbols  in 
the  Case  Report  are  not  referred  to  in  the  following  analysis. 

98 


and  the  patient  has  since  passed  it.  Cases  50,  220,  275 — ^ Perhaps 
lack  of  skill  resulted  in  these  symptomless  hernias,  or  bulging  scars 
following  acute  appendicitis  with  drainage.  Case  103 — Possibly 
the  errors  of  skill  resulted  in  orchidectomy.  Cases  138,  255— Small, 
symptomless  hernias  in  the  epigastric  wounds  in  patients  who  were 
relieved  of  lifelong  discomfort.  Case  124 — I  may  have  missed  an 
ulcer  of  the  stomach.  Case  241 — S.  J.  Mixter,  J.  G.  Mumford, 
H.  O.  ISIarcy,  M.  H.  Richardson,  and  C.  A.  Porter  also  failed  in 
this  case. 

Even  admitting  these  errors  of  skill,  we  know  that  all  these  cases 
had  good  results,  and  the  errors  only  caused  lack  of  perfection,  not 
failure. 

N.B.  I  am  perfectly  willing  to  admit  that  I  am  not  a  rapid  or 
skillful  operator,  but  I  insist  that  my  analysis  does  not  convict  me 
of  lack  of  skill. 

In  detail,  the  only  things  of  importance  in  which  I  find  a  lack 
of  technical  skill  or  knowledge  are  these: 

(a)   How  to  tell  that  you  have  removed  the  last  small  stone  from 

the  bile  passages. 
(&)    How  to  prevent  hernias  and  weak  scars  after  drainage  of 

appendicitis  wounds,  or  hematomas, 
(c)   How  to  make  sure  that  hematemesis  is  not  due  to  an  ulcer 

of  the  stomach. 

These  are  the  weaknesses  of  modern  surgery,  not  my  weaknesses. 
I  believe  my  percentages  are  as  low  as  anybody's.  I  go  about  to 
medical  meetings,  read  the  journals,  visit  hospitals,  study  hospital 
reports,  ask  questions  of  the  eminent,  but  get  no  satisfactory  replies. 

When  the  End  Result  Report  of  some  hospital  in  which  the 
Trustees  take  an  Inventory  of  their  Product  shows  that  some  surgeon 
has  mastered  these  important  problems,  I,  with  the  rest  of  the 
surgeons  of  this  country,  will  go  to  worship  at  their  shrine. 

Logical  conclusion:  If  my  analysis  has  been  self-searching  and 
accurate,  and  it  is  true  that  in  five  years  these  are  the  only  errors 
due  to  lack  of  technical  knowledge  or  skill,  it  may  be  fairly  con- 
cluded that  what  we  need  for  the  success  of  this  hospital  is  not  more 
skill,  but  more  patients. 

Errors  Possibly  Due  to  Lack  of  Judgment 

Trivial  errors  (17,  57,  104,  112,  156,  223,  282),  with  good 
results.  Case  33 — It  may  have  been  poor  judgment  to  drain  at  first; 
at  any  rate,  the  result  was  good.  Case  77 — Possibly  I  should  have 
removed  the  gall  bladder,  but  the  patient  is  still  well.  (P.  S.  See 
Abstract.)     Cases  167,  196,  232 — Perhaps  too  conservative. 

Logical  conclusions:  If  my  self-analysis  has  been  correct,  and 
these  errors  of  judgment,  together  with  those  involved  in  the  five 
cases  which  died,  are  the  only  ones  in  five  years,  where  can  I  find 

99 


better  judgment?  Do  the  End  Result  Reports  of  the  Great  Hos- 
pitals in  Boston  of  the  picked  cases  for  operation  before  the  Clinical 
Congress  of  Surgeons,  published  in  Surgery,  Gynecology,  and 
Obstetrics  for  October,  1916,^  show  instances  of  better  judgment? 
My  judgment  may  be  questioned  for  carrying  the  End  Result  Idea 
so  far  that  I  publish  my  own  errors,  but  I  defyany  public  or  private 
hospital  in  Boston  to  show  a  consecutive  series  of  results  which  will 
prove  better  Surgical  judgment. 

And  as  to  my  judgment  in  standing  alone  on  the  End  Result 
Idea, —  that  remains  to  be  proved,  for  Trustees  will  not  be  convinced 
until  the  Idea  comes  back  to  them  from  other  cities,  and  the  Bank 
Account  of  this  hospital  grows  to  be  worth  soliciting.  How  can 
they  be  expected  to  listen  to  an  Idea  without  a  Bank  Account,  when 
they  know  by  the  Bank  Accounts  of  Surgeons  on  their  Staffs  that 
the  Results  at  their  hospitals  must  be  good?  If  my  Bank  Account 
ever  grows  to  be  larger  than  that  of  my  competitors  at  the  so-called 
Charitable  Hospitals,  I  shall  certainly  be  offered  some  important 
position,  even  if  my  eyesight  is  failing  and  my  hand  trembles. 

Errors  Due  to  Lack  of  Care  or  Equipment 

There  are  certain  minor  complications  which  occur  in  the  healing 
of  wounds  which  are  of  no  great  importance  except  as  warnings: 
hematomas  which  absorb,  serous  discharges  which  "weep"  for  a  few 
days,  overlapping  of  the  skin  edges,  pus  in  the  stitch  holes,  stitch 
abscesses,  or  trifling  sepsis  in  the  subcutaneous  fat.  These  are  most 
often  errors  of  haste,  carelessness,  and  inaccuracy.  They  are 
common  in  the  Charitable  Hospitals,  because  the  busy  surgeons  sew 
up  the  wounds  hurriedly,  or  leave  them  to  assistants  to  get  their 
exiDcrience  on.  True,  to  each  individual  patient  they  are  not  very 
important  errors, —  they  merely  mean  a  few  unnecessary  or  painful 
dressings,  a  few  ugly  or  sensitive  scars,  etc. 

^The  surgeons  of  Boston  may  well  be  congratulated  on  being  the  only 
group  wlio  have  operated  before  the  Clinical  Congress  of  Surgeons  and  who 
have  reported  publicly  the  result  of  the  operation  in  each  case.  They  have 
not  asserted  their  superiority,  but  their  willingness  to  be  compared.  They 
have  stood  for  the  ])rinclple  that  the  public  display  of  operative  technique 
should  be  justified  by  a  public  report  of  the  success  or  failure  of  the  opera- 
tion. Amphitheater  exhibitions  are  given  to  increase  the  prestige  of  a 
hospital  and  its  individual  surgeons,  and  it  is  often  impossible  for  the  audi- 
ence to  be  sure  that  technical  skill  is  accompanied  by  good  surgical  judg- 
ment. It  is  to  Ije  liopcd  tiiat  future  Clinical  Congresses  will  follow  the 
example  set  by  the  Boston  surgeons,  for  an  End  Result  Report  of  the  cases 
operated  on  before  it  would  do  much  to  protect  the  patients.  To  the  surgeon 
operating  in  public,  there  is  always  the  temptation  to  sacrifice  essentials 
to  appearances. 


100 


Such  were  Cases : 

Stitch  abscess  or  fat  sepsis  — 18,  138,  155,  156,  189,  199, 
283,  302. 

Serum— 74,  174,  244,  248,  261,  265,  274,  280,  292. 

Hematoma— 282,  241,  255,  276,  281. 

Overlapping — 234,  235,  241,  279. 

These  occurred  in  25  operations  which  should  have  had  perfect, 
dry,  clean  wounds  to  which  the  gauze  applied  at  the  second  dress- 
ing would  not  adhere.  There  has  been  no  sepsis  which  has  caused 
any  serious  delay  in  the  convalescence,  or  any  ultimately  bad  result 
to  the  patient.  The  worst  cases  were  138  and  156, — read  their 
records.  Both  now  have  symptomless,  weak  scars.  All  the  other 
clean  cases  had  perfect  healing. 

What  can  we  do  to  avoid  even  these  minor  errors  in  the  future? 
For  where  these  trivial  complications  occur,  sooner  or  later  serious 
ones  will  follow,  as  they  do  at  those  Charitable  Hospitals  where 
analysis  of  the  responsibility  is  neglected. 

Those  cases  in  which  there  was  hematoma  or  serous  oozing 
have,  as  a  rule,  followed  the  local  use  of  novocaine  and  quinine  urea 
in  conjunction  with  general  anaesthesia,  and  we  consider  that  the 
relief  from  pain  justifies  this  slight  risk.  However,  we  have  dis- 
carded quinine  urea  as  an  unnecessary  adjunct  to  novocaine. 

Logical  conclusions:  In  five  years  there  has  been  no  death  from 
sepsis  or  even  a  serious  consequence,  although  Case  156  had  a  very 
narrow  margin,  and  now  has  a  weak  scar.  There  has  been  no  other 
bad  consequence  which  we  can  attribute  to  lack  of  care  or  equip- 
ment. Do  we  need  marble  halls  and  terrazzo  operating  rooms, 
vaulted  ceilings  and  expensive  sterilizers,  like  those  of  the  Chari- 
table Hospitals }  There  is  often  dust  in  our  corners,  the  floors  are 
of  wood,  the  instrument  boiler  cost  $0.87,  the  hot-water  sterilizers 
are  commercial  kitchen  utensils  (price,  $13.55),  and  both  our  X-ray 
machines  are  second-hand.  But  the  fact  remains  that  we  need  more 
patients  more  than  we  need  more  equipment  or  care.  Nevertheless, 
we  have  had  enough  errors  to  see  that  we  cannot  relax  our  care, 
if  we  are  to  continue  to  be  Standard-bearers  of  the  End  Result 
System.  More  equipment  we  shall  have,  when  the  fact  that  our  beds 
remain  full  justifies  it.  More  varied  equipment  might  justify  caring 
for  other  kinds  of  cases,  but  we  do  not  need  it  at  present  for  cases 
of  the  same  kind. 

Errors  Due  to  Incorrect  Diagnosis 

Cases  of  academic  importance  only:  1,  18,  105,  142,  189,  232, 
236,  237,  242,  244,  247,  251,  256,  272,  278,  284,  285,  295,  301,  302, 
308,  328. 

Cases  in  which  the  incorrect  diagnosis  led  to  an  unnecessary 
exploratory  operation:  Cases  51,  D6.  These  patients  would  have 
been  saved  a  certain  amount  of  pain  and  risk  by  omitting  the  primary 
operation.    Case   119 — In  this  case  of  recurrent  cancer,  the  supra- 

101 


clavicular  glands  were  removed,  and  showed  no  cancer  cells.  As  the 
patient  ultimately  died  of  cancer  of  the  lungs,  the  operation  was 
unnecessary,  as  well  as  an  error  in  diagnosis.  Case  145 — -A  cancer 
of  the  cardiac  end  of  the  stomach  was  found  to  be  inoperable. 
Case  213 — This  was  one  of  those  peculiar  cases  of  tuberculous 
peritonitis,  in  which  the  mere  opening  of  the  abdomen  apparently 
cured  the  disease.  Nevertheless,  I  think  it  is  very  doubtful  whether 
operation  should  be  undertaken  on  this  chance  alone. 

Cases  in  which  a  better  diagnosis  might  have  saved  the  patient 
trouble,  time,  or  expense:  Case  90 — This  patient  perhaps  has  gall- 
stones which  might  have  been  removed  when  the  appendix  was. 
Case  131 — We  should  have  tried  medicinal  treatment  before  oper- 
ating, but  the  result  was  perfect.  Case  332 — Probably  a  laparotomy 
should  have  been  done,  instead  of  simple  curettage  of  the  uterus. 

Logical  conclusions:  If  we  had  had  superhuman  diagnostic 
abilitj'',  we  should  have  been  saved  19  errors  of  academic  importance 
only ;  four  cases  would  perhaps  not  have  had  exploratory  operations ; 
and  four  patients  might  have  been  saved  some  time  and  trouble. 

Would  this  have  justified  our  employing  a  diagnostician  for 
five  years  ?  Certainly  not,  from  a  business  point  of  view.  How 
much  would  it  cost  to  employ  one  to  diagnose  every  case  and  register 
his  diagnosis  in  comparison  with  ours  ?  What  portion  of  our  average 
fee  of  $61.12  for  operation  and  three  weeks'  care  would  he  earn, 
if  he  did  this  }  In  how  many  of  these  cases,  in  which  I  failed,  would 
he  have  succeeded.'*  And  where  could  we  obtain  one  with  a  good 
record?  Is  there  any  hospital  which  records  the  accuracy  of  its 
diagnostic  staff? 

But  we  have  a  place  for  some  young  man  with  a  good  training, 
who  wants  to  learn  to  become  a  diagnostician.  We  will  give  him 
bed,  board,  lodging,  and  a  living  salary,  and  publish,  in  every  case, 
his  diagnosis  as  against  ours.  When  he  is  worth  it,  he  can  have  a 
share  in  the  business. 

Cases  in  Which  the  Nature  and  Extent  of  the  Disease 
Was  the  Main  Cause  of  Failure 

From  the  point  of  view  of  efficiency,  it  is  clear  that  this  hospital 
should  not  undertake  to  treat  cases  having  diseases  which  we  can- 
not cure  or  relieve.  We  ought  to  send  such  cases  to  persons  who 
are  more  expert,  or  who  have  studied  the  diseases  in  question 
particularly. 

In  our  analysis  of  our  cases,  we  find  that  in  the  following 
instances  we  had  to  deal  with  diseases  which  we  cannot  cure: 

Cases  of  cancer  which  have  recurred  or  died  since  leaving  the 
hospital:  10,  38,  39,  42,  53,  68,  78,  85,  119,  145,  146,  204,  231,  232, 
237,  258,  268,  269,  327,  331,  337. 

In  all  these  cases  we  were  able  to  prolong  life  and  to  relieve 
suffering,  although  we  could  not  cure  them.  On  the  other  hand, 
we  have  the   following  cases  of  cancer  which  at  varying  intervals 

102 


since  the  operation  have  been  reported  as  still  well:  4:6,  51,  110, 
114,  133,  148,  151,  186,  223,  252,  261,  267,  270,  284,  291,  296,  298, 
308,  326. 

Neurotic  individuals  who  had  surgical  conditions  and  were 
helped,  but  not  perfectly  relieved:  74,  94,  116,  117,  189,  241, 
289,  319. 

Besides  these,  we  find  the  following  conditions  which  we  have 
not  been  able  materially  to  benefit,  and  which  therefore  are  classes 
of  cases  we  do  not  care  to  undertake  to  cure  in  the  future:  Case  8 — 
Banti's  disease.  Cases  47,  332 — Dysmenorrhoea  from  anteflexion. 
Case  54 — Oblique  fracture  of  clavicle.  Cases  76,  178,  293 — Chronic 
nephritis.  Cases  96,  287,  298 — Diabetes.  Case  127 — Neglected 
empyema.  Case  137 — Tuberculosis  of  the  lungs.  Case  221 — Multi- 
ple diseases.  Case  253 — Epilepsy.  Case  292 — Vegetative  endocar- 
ditis. Case  304 — Enlarged  seminal  vesicle.  Case  336 — Chronic 
bacteriuria. 

We  shall  watch  other  hospital  Reports  to  see  where  to  send  these 
cases  in  the  future. 

Logical  conclusions:  We  do  not  want  to  undertake  the  treat- 
ment of  cases  of  advanced  cancer ;  ptosis  and  neurasthenia ;  Banti's 
disease;  anteflexion;  oblique  fractures  of  the  clavicle  in  young 
ladies  who  wear  low-neck  gowns;  chronic  nephritis;  neglected 
empyema ;  pulmonary  tuberculosis ;  epilepsy ;  endocarditis ;  bac- 
teriuria ;  diabetes ;  or  enlarged  seminal  vesicles. 

We  know  that  we  do  not  have  success  with  these  conditions, 
and  we  doubt  if  anybody  else  does ;  but  we  do  want  to  keep  informed 
as  to  what  men  are  working  on  the  study  of  these  conditions,  and 
could  therefore  probably  give  the  best  possible  up-to-date  treatment 
to  our  patients. 

For  instance: 

Case  278  has  taught  us  that  Dr.  Henry  Christian,  by  his  years 
of  study  of  nephritis,  is  able  to  prove  it  by  some  actual  benefit  to 
the  patient. 

Case  308  has  taught  us  that  the  $150,000  worth  of  radium  at 
the-  Huntington  Hospital  is  capable  of  producing  magical  good  in 
at  least  one  case  of  inoperable  cancer. 

Case  8  has  led  us  to  find  that  Dr.  Beth  Vincent,  who  has  devoted 
time  and  energy  to  studying  blood  conditions,  has  improved  cases 
of  splenic  ansemia,  the  forerunner  of  Banti's  disease,  by  splenectomy. 

Case  137  has  led  us  to  know  of  the  unfailing  care  and  kindness 
of  Dr.  Chadwick,  of  the  Westfield  Sanatorium. 

But  we  are  still  in  doubt  about  the  proper  person  to  whom  to 
refer  our  cases  of  dysmenorrhoea  from  anteflexion. 

Our  future  policy  will  be  to  keep  a  card  catalogue  of  all  the 
specialists  in  Boston,  and  by  comparing  their  scientific  papers  with 
the  Reports  of  their  hospitals,  find  out  whether  their  study  has 
enabled  them  to  prove  that  they  can  cure  the  diseases  on  which  they 
write  and  in  which  they  specialize.    If  we  find  that  they  do,  we  shall 

103 


invite  them  to  join  our  Consulting  Board,  or  shall  refer  our  well- 
to-do  patients  to  them. 

If  any  one  not  on  the  staff  of  a  Charitable  Hospital  thinks  this 
unfair,  he  can  bring  his  cases  to  our  hospital,  and  we  will  do  his 
advertising  for  him,  if  he  will  take  the  chance  as  we  do.  He  need 
bring  only  the  cases  he  expects  to  cure. 

Cases  Who  Refused  to  Accept  Treatment 

Certain  cases  came  to  this  hospital  too  late  for  a  satisfactory 
operation,  although  they  had  been  urged  by  their  physicians  to  have 
an  operation  at  a  time  when  their  diseases  could  have  been  satis- 
factorily conquered.  For  instance.  Case  275  had  permitted  an 
appendicial  abscess  to  accumulate,  and  continued  to  refuse  relief 
by  operation.  She  paid  for  it  with  a  prolonged  convalescence,  an 
appendicial  fistula,  and  a  second  operation  for  removal  of  the 
appendix.  Case  231  probably  lost  her  life  by  refusing  to  have  an 
ovarian  cyst  removed,  when  it  could  have  been  safely  done ;  and 
only  consented  to  operation  after  the  cyst  had  ruptured,  and  metas- 
tases had  spread  throughout  the  abdominal  cavity. 

In  one  case  (Case  8)  the  reverse  was  true.  Dr.  Harrington, 
Dr.  Chute,  and  I  advised  exploration  of  the  kidney  in  a  case  of 
hematuria.  The  patient  refused,  and  later  autopsy  showed  that  the 
operation  would  have  been  useless.  The  spleen  should  have  been 
removed. 

Of  the  other  cases  which  refused  operation,  we  do  not  know  the 
result  in  Cases  35,  84,  122,  164,  230.  In  Case  111,  we  probably 
could  have  helped  the  patient.  Case  151  is  now  well,  but  she  took 
grave  chances,  and  endured  more  discomfort  than  the  operation 
would  have  caused  her. 

In  five  years  we  find  very  few,  if  any,  real  errors  due  to  the 
lack  of  cooperation  of  the  patients  while  in  this  hospital,  and  these 
errors  were  in  most  cases,  perhaps,  due  to  our  lack  of  conviction  in 
the  advice  we  gave.  In  other  words,  we  have  advised,  not  urged 
or  insisted  on  operation  in  these  cases.  We  have,  as  a  rule,  found 
patients  too  ready  to  be  operated  upon,  rather  than  the  reverse. 
Of  course,  in  most  cases,  patients  who  come  to  us  have  already  been 
convinced  of  the  necessity  of  operation  by  their  own  physicians,  and 
in  our  opinion  this  important  counsel  is  one  for  which  the  physicians 
get  too  little  credit  and  make  too  small  a  charge.  What  can  we  do, 
in  the  future,  to  diminish  the  number  of  errors  due  to  patients'  not 
seeking  operation  in  time.'' 

Logical  conclusion:  Reduce  the  price  of  our  consultation  fee  for 
thorough  examination  by  precise  methods,  such  as  the  X-ray  and 
laboratory  tests,  etc.,  to  a  low  enough  figure,  so  that  the  patients 
and  their  physicians  will  not  be  withheld  from  seeking  our  advice 
on  account  of  the  financial  burden.  This  we  are  doing  by  the  group- 
ing of  specialists  proposed.  If  we  can  let  every  one  in  the  Com- 
munity know  that  they  can  obtain  a  high  standard  diagnosis  at  a 

104 


certain  fixed  sum,  we  believe  many  will  be  induced  to  seek  profes- 
sional advice  earlier  than  they  do  now.  We  plan  to  compete  with 
the  Massachusetts  General  Hospital  clinic,  which  already  performs 
this  service  to  a  certain  extent.  We  plan  to  show  the  Community 
that  we  can  do  the  work  better.  Our  charge  will  be  fixed  at  a  low 
enough  figure  to  compete  with  that  of  the  Massachusetts  General 
Hospital. 

Deaths 

Five  of  my  cases — 24,  45,  224,  230,  305  —  died  while  in  the 
hospital.  In  these  five  cases,  it  is  difficult  to  attribute  the  failure 
to  any  one  cause.  All  were  necessarily  errors  of  judgment,  because 
they  resulted  in  failure.  In  each  case  I  knew  that  the  chance  for 
the  patient  was  very  small,  but  as  all  of  the  patients  suffered  so 
intensely  that  life  was  unendurable,  it  seemed  only  fair  to  give  each 
of  them  the  chance  of  cure  by  operation. 

Because  I  took  that  chance  and  failed,  it  convicted  me  of  having 
a  lack  of  sufficient  ability  to  save  these  patients.  As  may  be  seen 
by  the  histories,  there  was  a  very  narrow  margin  between  success 
and  failure.  In  each  case  there  was  some  minor  error  of  diagnosis. 
Possibly,  had  we  made  sure  of  the  diagnosis  before  operating,  we 
might  have  saved  some  of  these  patients.  It  is  clear  that  if  w^e  had 
not  operated,  death  due  to  the  patients'  diseases  would  have  occurred 
before  many  months  or  years,  for  these  conditions  are  among  the 
gravest  that  come  to  a  surgeon. 

In  none  of  these  five  cases  could  the  patient  be  considered  blame- 
less, so  far  as  refusal  of  treatment  was  concerned.  They  all  accepted 
my  advice,  but  in  the  early  stages  of  their  diseases,  when  operation 
would  have  offered  a  really  favorable  chance,  they  ignored  the 
writing  on  the  wall.  All  of  them  were  strong-willed,  brave  persons, 
and  fought  their  fight  with  the  disease  for  a  long  period  before 
submitting  to  medical  advice,  and  even  after  the  operation  kept 
their  courage  to  the  end. 

Naturally,  we  do  not  wish  to  care  for  similar  cases  in  the  future ; 
and  should  such  cases  come  to  us,  we  shall,  so  far  as  our  judgment 
can  permit  us,  call  in  the  best  surgeon  we  can  get  from  the  staff 
of  one  of  the  Charitable  Hospitals,  because  these  surgeons  are 
appointed  by  Trustees  as  the  best  Surgeons  in  the  Community. 

Logical  conclusions :  Since  we  can  call  one  of  the  best  surgeons 
for  such  cases,  why  take  charge  of  similar  ones  in  the  future  ?  Even 
the  great  surgeons  must  be  willing  to  operate  for  nothing. 

What  can  we  do  about  these  "bad  risks"  in  the  future?  As  we 
explained  in  our  last  Report,  a  certain  number  of  deaths  are  neces- 
sary to  the  surgeon  in  his  business.  A  surgeon  whose  cases  always 
get  well,  gets  no  reputation  for  "nerve."  It  is  said  that  he  will  not 
take  a  chance  when  he  ought  to  do  so.  A  surgeon  must  be  "fearless" 
and  "bold,"  and  the  only  way  he  can  prove  that  he  is,  is  by  a  death 
now  and  then  in  his  practice. 

105 


Shall  I  say  in  the  future  ?  : 

1.  You  are  too  bad  a  risk;  go  to  a  first-class  surgeon. 

2.  You  are  a  bad  risk;  I  must  double  my  usual  fee. 

3.  You  are  a  bad  risk;  you  need  not  pay  unless  you  live. 
All  are  logical.     I  like  the  last  best. 

Calamities 

A  committee,  in  investigating  cases  of  errors  in  a  large  hospital, 
would  unavoidably  find  certain  cases  in  which  failure  was  due  to 
the  fault  of  nobody.  For  instance,  there  are  certain  cases,  such 
as  pulmonary  embolism,  status  lymphaticus,  heart  failure,  etc.,  which 
no  one  is  wise  enough  to  foresee,  and  yet  which  occur  with  sufficient 
frequency  to  be  a  constant  concern  to  surgeons.  What  per  cent  of 
such  cases  would  be  a  fair  allowance.^  Of  the  260  cases  on  whom 
I  have  operated  at  this  hospital  during  five  years,  one  has  suffered 
from  a  calamity  of  this  kind: 

Case  i5,  a  nephrectomy  for  stone  (see  page  17),  died  suddenly 
after  the  wound  had  healed,  and  just  before  the  time  the  patient 
had  planned  to  go  home.  She  had  very  bad  organic  heart  disease, 
but  as  the  operation  had  been  a  nephrectomy,  it  is  probable  that 
death  was  due  to  pulmonary  embolism  rather  than  to  heart  disease. 
If  it  was  due  to  embolism,  it  was  a  Calamity;  if  it  was  due  to  heart 
disease,  there  was  an  error  of  judgment  in  estimating  the  strength 
of  the  heart. 

If  End  Result  reports  existed  in  the  large  hospitals,  a  definite 
ratio  of  such  Calamities  could  be  established,  and  definite  studies 
made  of  their  character,  causes,  and  means  of  prevention.  My  own 
ratio  of  Calamities  has  been  1  to  260. 

Logical  conclusions :  What  can  we  do  to  prevent  similar  calami- 
ties in  the  future .''  By  a  constant  review  of  the  literature  on  pul- 
monary embolism,  we  should  become  able,  as  soon  as  experimental 
science  or  clinical  reports  show  that  pulmonary  embolism  can  be 
prevented,  to  ascertain  the  methods  which  will  protect  our  patients 
from  it.  If  our  hospital  were  larger  and  well  financed,  we  might 
devote  sjDccial  research  to  the  question;  we  are  interested  in  what' 
is  being  done  at  the  New  York  Hospital  in  investigating  this  subject. 

A  review  of  the  cases  on  page  143  which  died  at  the  Massachu- 
setts General  Hospital  following  my  operations,  shows  that  lung 
emboli  and  lung  infections  (probably  usually  combined)  are  the 
most  common  cause  of  operative  mortality.  The  published  reports 
of  the  causes  of  death  in  the  Annual  Reports  of  the  Peter  Bent 
Brigham,  Boston  City,  and  Massachusetts  General  Hospitals  show 
the  same  thing.  Yet,  so  far  as  I  know,  none  of  us  are  devoting  time^, 
money,  and  energy  to  finding  the  cause  and  method  of  prevention., 
of  this  greatest  enemy  of  modern  operative  surgery. 


106 


If  I  can  thus  analyze  my  errors  and  deficiencies,  a  Charitable 
Hospital  can.  Before  Trustees  vote  more  funds  for  new  buildings 
and  equipment,  let  them  appoint  Efficiency  Committees  to  make 
analyses  of  the  results  they  are  getting  now.  They  can  then  decide 
whether  to  spend  their  money  for  improvement  in  quality  or  in 
quantity, —  for  products  or  waste  products. 


107 


PART  II 

THE   FINANCIAL   REPORT 

AN  ILLUSTRATION  OF  THE  MONEY  VALUE  OF  A  SURGEON'S 

SERVICES  AND   THE  INFLUENCE  OF  THE  CHARITABLE 

HOSPITALS  UPON  IT 


PAGE 

Ego 109 

A  Few  of  the  Things  on  Which  I  Do  Not  Agree  with 

Richard  Cabot          .......  113 

The  Value  of  Surgical  "Material"      .         ,         .         .  115 

The  Concept  of  This  Hospital      .         .         .         .         .  117 

Assets  and  Liabilities,  with  Remarks    .         .         .         .  118 

Receipts  and  Expenditures,  with  Remarks   .          .          .  119 

Competition  with  the  Charitable  Hospitals         .         .  120 
Comparison    of     Percentages    of    Various    Items    of 
Expense   of   Peter   Bent   Brigham   Hospital  and 

CoDMAN  Hospital     .......  123 

Balance  Sheet  of  the  Commercial  Surgeon  and  His 

Conscience        ........  125 

Balance    Sheet    of    the    Hospital   Surgeon    and    His 

Conscience        ........  126 

Cheap  Operations  ........  126 

The  Value  of  My  Time 127 

The  Value  of  An  Operation          .....  129 

Has  This  Hospital  Been  a  Success?       ....  130 

Why  This  Hospital  Has  Not  Been  a  Financial  Success,  132 

In  the  Event  of  Financial  Success      ....  135 

A  Surgeon's  Reward       .......  136 

Eccentricity  .........  136 

Offers  to  Charitable  Hospitals    .....  137 

The  Proof  That  the  Writer  Deserves  An  Appoint- 
ment AT  A  Charitable  Hospital       .          .          .          .  139 

Diagnoses  of  the  141  Cases  Which  Died  after  Opera- 
tion BY  E.  A.  C.  at  the  Massachusetts  General 

Hospital  During  the  Years  1900  to  1914  Inclusive,  142 

Bibliography  .........  156 


PART  II 

THE   FINANCIAL   REPORT 

AN  ILLUSTRATION  OF  THE  MONEY  VALUE  OF  A 

SURGEON'S  SERVICES  AND  THE  INFLUENCE 

OF  THE  CHARITABLE  HOSPITALS  UPON  IT 


Ego 

"Success  treads  on  every  right  step.  For  the  instinct  is  sure  that 
prompts  him  to  tell  his  brother  what  he  thinks.  He  then  learns  that  in  going 
down  into  the  secrets  of  his  own  mind,  he  has  descended  into  the  secrets 
of  all  minds.  He  learns  that  he  who  has  mastered  any  law  in  his  private 
thoughts,  is  master  to  that  extent  of  all  men  whose  language  he  speaks,  and 
of  all  into  whose  language  his  own  can  be  translated. 

********* 

The  deeper  he  dives  into  his  privatest,  deepest  presentiment,  to  his 
wonder  he  finds  this  is  the  most  acceptable,  most  public,  and  universally 
true." — Emerson. 

I  started  the  practice  of  surgery  primarily  to  make  an  honest 
living.  At  first  I  was  guided  by  the  example  of  men  who  were 
generally  respected^  mainly  my  teachers.  It  was  their  custom^  and 
had  been  the  custom  of  their  teachers  before  them,  to  undertake 
treatment  because  the  patient  sought  their  aid,  even  if  they  knew 
that  other  available  colleagues  were  more  competent  to  obtain  a 
good  result  for  that  particular  disease  for  which  the  patient  con- 
sulted them.  It  was  the  custom  in  the  hospitals  to  which  as  a  student 
I  was  led  by  Harvard  University,  for  the  visiting  staffs  to  give 
treatment  or  to  operate  by  the  ward,  by  the  calendar,  or  by  the  time 
of  day,  seldom  because  of  the  particular  study  of,  or  demonstrated 
ability  to  succeed  in  relieving,  the  condition  in  hand.  Again  and 
again  I  have  seen  surgeons  who  had  given  special  study  to  some 
particular  group  of  cases,  stand  by  and  watch  some  colleague  do 
what  they  knew  was  the  wrong  operation,  or  else  patiently  suggest 
to  their  colleague  what  ought  to  be  done,  and  even  then  watch  him 
take  some  step  which  would  lead  to  death  or  lifelong  misery. 

I  saw  cases  lying  relatively  neglected  in  the  wards  of  surgeons 
who  took  no  interest  in  that  particular  disease,  and  at  the  same  time 
other  surgeons,  who  were  interested  in,  and  had  made  special  study 
of  such  cases,  standing  idle  because  of  the  calendar.  I  saw  dis- 
tinguished medical  professors  hold  over  for  a   future  clinic,  cases 

109 


which  obviously  needed  immediate  operation.  As  a  young  surgeon^  I 
did  at  night  the  most  serious  and  difficult  operations^  and  in  the  day- 
time watched  the  great  surgeons  hurriedly  do  trivial  and  simple  ones. 
Operations  like  that  for  hernia  (in  which  careful  asepsis  means 
more  than  skill)  were  done  hurriedly  by  busy  surgeons,  and  cases  ■ 
of  cancer  of  the  stomach,  which  require  a  long,  tedious  operation, 
were  discharged  without  operation,  as  hopeless.  Sometimes  sixty 
patients  were  visited  and  several  patients  operated  on  by  a  man 
with  "reputation"  in  an  hour.  No  one  ever  thought  of  contrasting 
the  results  of  such  work  with  that  of  some  plain,  conscientious  man 
without  a  "reputation,"  who  was  able  to  take  plenty  of  time  for  each 
case. 

Thus  r  was  taught  by  eminent  example  that  these  abuses  were 
necessary  in  the  practice  of  surgery,  just  as  "business  methods" 
are  necessary  in  successful  business.  "Human  nature  is  essentially 
bad,  and  a  wise  man  must  be  content  with  being  a  little  bit  better 
than  the  average!" 

When  I  entered  private  practice,  too,  I  found  I  must  take 
whatever  cases  came  to  me;  and  that  as  I  had  my  living  to  earn, 
I  could  not  be  expected  to  refer  to  those  more  competent,  every  case 
that  came.  I  must  make  my  errors  just  as  those  before  me  had. 
I  was  ambitious  to  be  a  surgeon,  and  it  became  at  once  apparent 
that  I  must  do  one  of  two  things : 

Either  I  must  obtain  a  hospital  appointment,  or 

I  must  take  advantage  of  every  patient  that  came  to  me,  and  let 
him  think  that  I  was  as  competent  a  surgeon  as  he  could  get. 

Through  family  position,  acquaintances,  well-wishers  on  the 
Staff  and  Board  of  Trustees  of  the  Massachusetts  General  Hospital, 
I  was  able  to  secure  a  position  as  Assistant  Surgeon  there. 

Immediately  the  cases  that  came  under  my  care  were  as  grave 
and  difficult  as  any  I  have  had  since.  They  came  by  the  time  of  day, 
or  of  the  month,  or  by  the  number  of  the  ward,  the  changes  in  the 
calendar,  or  the  absence  of  my  Seniors.  It  was  a  wonderful  oppor- 
tunity for  a  young  man  to  get  major  surgical  experience,  but  I 
cannot  think  it  was  fair  to  some  of  the  patients.  However,  it  was 
long  before  it  occurred  to  me  that  any  other  method  of  distributing 
the  cases  among  the  members  of  the  Staff  was  possible.  I  did  what 
every  other  surgeon  had  done  before  me,  and  was  grateful  for  the 
opportunity. 

After  fifteen  years'  service,  during  which  the  possibility  and 
practicability  of  the  End  Result  System  had  occurred  and  recurred 
to  me  with  ever  increasing  force,  I  resigned  as  a  protest  against  the 
Seniority  System  of  Promotion,  under  which  I  had  attained  high 
rank  and  to  which  I  have  been  indebted  for  the  excellent  surgical 
experience  and  training  whicli  I  have  had.  My  enemies  might  even 
say  that  I  took  all  the  good  I  could  out  of  the  hospital,  and  quit 
before  doing  my  share. 

I  saw,  year  after  year.  Seniors  who  used  the  hospital  chiefly 

110 


to  increase  their  own  prestige  and  practice,  continue  to  hold  positions 
which  rightly  belonged  to  Juniors,  who  did  their  work  for  the  hos- 
pital and  its  patients.  I  saw,  ranking  below  me,  surgeons  who  were 
evidently  more  competent  than  some  of  those  above  me.  I  saw 
energetic,  ambitious  young  men  leaving  the  hospital,  because  it  was 
obvious  that  nepotism  and  seniority  would  never  give  them  a  fair 
show.  In  short,  I  saw  that  such  hospital  positions  were  sinecures, — 
valuable  as  seats  in  the  Stock  Exchange, —  and  not  what  they  pre- 
tended to  be, — honorable  positions,  guaranteeing  merit.  Although 
I  myself  had  achieved  my  position  by  nepotism,  and  maintained  it 
by  seniority,  I  would  do  so  no  longer. 

If  I  could  not  claim  my  position  through  aggressive  merit,  I 
would  no  longer  hold  it  in  contented  complacency.  I  would  call  the 
Trustees  to  make  good  the  following  statement  which  they  had  pro- 
claimed, or  else  admit  that  it  was  a  Pretense: 

"Resolved,  that  in  making  appointments  the  Trustees  will  con- 
sider the  fitness  of  the  applicant  for  the  special  services  which  he 
will  be  called  on  to  perform,  and  will  seek  to  secure  the  best  service 
available,  without  being  bound  by  any  custom  of  promotion  by 
seniority." 

This  makes  a  promise  which  apparently  they  do  not  intend  to 
fulfill. 

I  therefore  resigned,  immediately  after  they  had  moved  my 
senior  up  a  step.  I  then  reapplied  for  the  position  of  surgeon-in- 
chief,  on  the  ground  that  the  results  of  my  cases  had  been  better 
than  those  of  any  other  surgeon. 

Trustees  cannot  understand  this  attitude  of  mind, — that  a  man 
should  give  up  a  comfortable  (supposedly  honorable)  position  and 
claim  by  merit,  and  insist  on  maintaining  by  merit,  the  same  posi- 
tion which  he  had  already  snugly  attained  by  nepotism,  and  was 
almost  sure  to  continue  to  enjoy  by  seniority.     Such  a  man  they 

distrust. 

"Let  me  have  men  about  me  that  are  fat, 
Sleek-headed  men,  and  such  as  sleep  o'  nights; 
Yon  Cassius  has  a  lean  and  hungry  look; 
He  thinks  too  much:  such  men  are  dangerous." 

But  the  fact  is  this:  I  have  returned  to  that  vague  state  of 
private  practice  where  I  am  in  competition  with  the  Charitable 
Institutions,  on  the  one  hand,  and  their  Staffs  on  the  other.  I  now 
realize  that  these  institutions  and  their  staffs  are  "Combinations  in 
the  Restraint  of  Trade." 

But  why  should  I  not  do  what  every  young  surgeon  or  every 
surgeon  without  exceptional  hospital  opportunities  should  do, — 
attempt  only  those  operations  which  I  feel  sure  will  result  favorably .'' 

Here  is  where  the  competition  with  Charitable  Institutions 
(Combinations  in  Restraint  of  Trade)  comes  in. 

Dr.  A.  is  a  private  surgeon  with  no  hospital  appointment  or 
"reputation,"   but   who   fully   intends   to   do   what  is   right   by   his 

111 


patients,  that  is.  to  charge  a  reasonable  sum  for  his  labor,  and  to 
undertake  only  operations  which  he  is  qualified  to  do.  He  is  ready 
to  give  time,  care,  and  personal  attention  to  his  patient,  and  does 
not  pretend  to  be  "the  best  surgeon." 

Dr.  B.  is  a  hospital  surgeon  appointed  by  the  Trustees  to  attend 
their  patients,  because  "he  is  the  best  man  they  can  get."  The 
position  is  a  guarantee  that  he  has  abundant  opportunities  to 
practice  different  forms  of  operations  and  to  keep  up  with  modern 
advances.   Which  of  these  would  you  select  for  your  surgeon,  reader.'' 

Now  put  yourself  in  Dr.  A.'s  place,  in  case  patients  come  to  him. 
Dr.  A.,  if  he  wishes,  can  always  get  Dr.  B.  to  do  the  operation  for 
him  for  the  asking.  Dr.  B.  has  the  best  chance  for  all  classes  of 
patients.  If  the  patient  is  poor.  Dr.  B.  can  take  him  into  his 
Charitable  Hospital  free  of  charge.  If  the  patient  has  a  moderate 
income,  Dr.  B.  can  underbid  Dr.  A.  without  loss.  If  the  patient  is 
rich,  he  will,  of  course,  engage  Dr.  B.,  because  he  can  afford  to  do 
so,  and  this  will  compensate  Dr.  B.  for  his  so-called  Charity. 

If,  whatever  the  circumstances  of  the  patient,  the  operation 
is  a  difficult  one,  Dr.  A.  has  no  moral  right  to  do  it,  if  he  can  get 
Dr.  B.,  because  Dr.  B.  is  having  constant  practice.  And  as  a  matter 
of  policy,  if  anything  went  wrong,  Dr.  A.'s  reputation  would  not 
stand  it;  while  Dr.  B.'s  position  on  the  Staff  of  the  "God  Have 
Mercy  On  Us  Hospital"  would  cover  a  multitude  of  sins,  even  if 
this  position  Vv^ere  obtained  by  nepotism  and  maintained  by  seniority. 
The  only  thing  Dr.  A.  can  conscientiously  do,  is  to  persuade  himself 
and  his  patients  that  by  excessive,  painstaking  care  he  can  compen- 
sate for  Dr.  B.'s  skill  and  experience  (and  habit  of  hurry),  or  do 
the  work  for  less  money. 

But  where  does  the  injustice  or  inefficiency  of  all  this  come  in? 
Simply  in  this, —  that  the  Trustees  of  our  Hospitals  give  Dr.  A.  no 
fair  show,  and  Dr.  B.  an  unfair  show. 

If  they  kept  Dr.  B.  up  to  time, — made  him  demonstrate  his  skill 
and  knowledge  by  his  results,  and  gave  Dr.  A.  a  chance  too,  it 
would  be  quite  a  different  matter.  Incidentally  they  would  get 
their  own  work  done  better,  and  be  able  to  recommend  competent 
physicians,  surgeons,  and  specialists  to  the  Public. 

I  have  sympathy  for  Dr.  A.,  because  even  with  all  Dr.  B.'s 
early  advantages,  in  real  training,  I  am  reduced  to  Dr.  A.'s  position. 
I  have  to  run  a  hotel  to  compete  with  the  Charitable  Hospitals.  I 
have  to  assume  responsibilities  which  Dr.  B.  shirks  under  cover  of 
his  Hospital  appointment.  I  want  to  bring  him  out  in  the  open 
for  a  fair  fight,  to  see  who  can  serve  the  Public  better.  I  would 
gladly  be  beaten  in  fact  by  Dr.  B.,  if  he  can  and  does  do  better  work 
than  I  do;  but  not  because  his  Hospital,  xcithout  looking  into  his 
■work,  guarantees  him. 

By  following  Emerson  and  thus  exposing  my  own  "soreness" 
with  the  Trustees  of  the  Massachusetts  General  Hospital,  I  hope 
to  find  that  what  I  have  to  say  is  "most  acceptable,  most  public, 

112 


and  most  universally  true,"  for  my  grievance  is  the  same  as  that 
of  many  a  young  surgeon  who  wants  to  take  his  place  by  merit 
instead  of  by  pull. 

A  Few  of  the  Things  on  Which  I  Do  Not  Agree 
WITH   Richard   Cabot 

Two  years  ago  it  occurred  to  me  that  publication  of  the  End 
Results  of  some  2,000  operations  which  I  had  performed  at  the 
Massachusetts  General  Hospital  would  be  a  more  effective  illustra- 
tion of  the  use  of  the  End  Result  System  than  the  few  hundred 
which  I  give  in  these  Reports.  I  went  to  Dr.  Washburn,  the  Admin- 
istrator of  the  Hospital,  for  his  permission  to  send  for  the  cases  on 
whom  I  had  operated  (of  which  I  have  a  card  catalogue)  to  come 
to  see  me  at  my  hospital,  so  that  I  could  examine  them,  and  thus 
make  a  complete  report.  I  also  told  him  that  I  should  be  glad  to 
let  these  persons  know  that  I  now  have  a  private  hospital  for  persons 
of  moderate  means,  to  which  they  or  their  friends  might  come  if 
future  operations  were  needed. 

Dr.  Washburn  most  politely  replied  that  he  would  be  glad  to 
have  me  send  for  the  cases,  but  that  he  could  not  permit  me  to  ask 
them  to  come  to  my  hospital  for  examination,  as  the  patients  belonged 
to  his  hospital,  and  they  might  be  tempted  to  come  to  my  hospital 
for  treatment.  He  kindly  said  that  I  could  examine  them  at  the 
Massachusetts  General  Hospital,  if  I  would  go  down  there  to  do  it. 
I  explained  that  I  could  not  afford  to  do  this,  as  I  had  to  be  on  hand 
at  my  own  hospital,  which  Avas  losing  money.  Time  spent  at  his 
hospital  in  doing  work  like  that  meant  that  I  must  charge  my  own 
patients  for  that  time.  As  I  had  already  lowered  my  own  prices  to 
zero,  to  compete  with  the  Massachusetts  General,  and  was  playing 
a  losing  game,  how  could  I  afford  to  spend  time  away  from  my  office 
on  such  altruistic  work  as  looking  up  old  cases.'' 

Dr.  Washburn's  attitude  seemed  to  me  so  unfair  (although  it  is 
substantially  the  same  as  that  in  all  hospitals),  that  for  some  time 
I  was  so  disgusted  I  did  nothing  about  it  at  all.  Later,  I  talked 
with  him  again,  saying  I  could  not  see  what  harm  it  would  do,  if 
a  former  member  of  the  Staff,  honorably  discharged,  did  succeed 
in  inducing  some  of  his  old  patients  to  employ  him.  It  even  seemed 
to  me  that  it  might  relieve  some  of  the  pressure  at  his  hospital,  and 
allow  the  Staff  time  to  do  its  work  a  little  better ! 

The  Administrator  referred  me  to  the  Executive  Committee, 
consisting  of  Dr.  Scudder,  Dr.  Porter,  Dr.  Edsall,  Dr.  Cabot,  and 
himself.  I  spoke  for  a  few  minutes  before  them,  trying  to  make 
them  understand  that  in  refusing  this  request  they  were  thi'owing 
work  on  their  Hospital  which  I  could  perfectly  well  perform  to  the 
satisfaction  of  the  patients  (that  is,  supposing  some  of  my  old  cases 
did  employ  me). 

"Why!"  said  Dr.  Cabot,  "if  we  allowed  you  to  see  our  patients 
at  your  hospital,  we   should  have   to   allow   every  member   of   our 

113 


Staff  a  like  privilege,  and  we  should  have  no  clinic  left!"  And  the 
Executive  Committee  voted  unanimously  to  back  up  Dr.  Washburn 
in  refusing  me  the  privilege  of  sending  for  the  cases  to  come  to  my 
hospital  for  examination. 

I  tried  to  explain  to  them  that  their  hospital,  aided  by  a  subsidy, 
was  competing  with  mine ;  that  they  were  wronging  all  young  men 
whom  I  might  employ  to  help  me  in  my  honest  work.  I  was  willing 
to  refer  back  to  their  hospital  all  difficult  and  interesting  cases,  but 
cases  like  hernia  or  fibroids,  which  I  could  cure  as  well  as  their  Staff 
could,  were  due  me  (and  any  young  surgeons  I  might  employ)  to 
make  a  living  out  of,  in  return  for  the  goods  I  was  able  to  deliver. 

I  tried  to  show  them  that  they  were  graduating  students  who 
must  make  their  living  in  private  practice.  If  the  Massachusetts 
General  Hospital  allowed  me  to  make  a  small  profit  out  of  success- 
fully treating  simple  cases,  I  could  build  up  a  business  large  enough 
to  employ  some  of  these  young  men  whom  they  were  graduating. 
This  would  save  the  young  men  the  necessity  of  undertaking  to 
treat  cases  they  were  not  qualified  to  treat,  as  they  had  been  taught 
to  do  at  the  Hospital  by  the  example  of  their  seniors. 

I  think  that  not  a  man  in  the  room,  not  even  Dr.  Cabot,  had  fore- 
sight enough  to  see  what  I  meant.  The  idea  may  be  brought  out 
differently,  in  this  way:  Dr.  Cabot  insists  on  criticizing  the 
present-day  practitioner,  who  was  taught  by  example  that  every 
doctor  has  a  right  to  his  patients,  just  as  Dr.  Cabot  says  that  the 
Massachusetts  General  has  a  right  to  its  patients.  What  he  should 
do,  instead  of  blaming  the  present-day  men  who  are  barely  earning 
a  living,  is  to  bring  up  a  new  generation  of  practitioners,  whose 
ethics  are  that  they  have  no  right  to  their  patients,  unless  they  can 
diagnose  the  cause  of  their  symptoms,  and  remove  the  underlying 
pathological  condition  as  surely  and  safely  as  any  one  else. 

We  shall  never  teach  the  practitioner  not  to  accept  cases  he 
is  not  qualified  to  cure,  while  the  hospitals  show  medical  students, 
by  example,  that  they  have  a  right  to  treat  patients  by  the  ward  or  by 
the  calendar.  If  the  hospital  maintains  a  right  to  the  patient, 
whether  it  can  cure  him  or  not,  so  will  the  practitioner.  Any  intelli- 
gent student  sees  little  moral  difference  between  his  own  right  to 
experiment  and  that  of  a  member  of  the  Staff  who  accepts  that  right 
by  nepotism  and  maintains  it  by  the  custom  of  Seniority  Promotion. 

But  why  pitch  on  Richard  Cabot  and  make  him  responsible  for 
things  which  are  common  abuses  in  many  hospitals,  and  perhaps 
less  in  his  hospital  than  in  others?  Simply  because  he  seems  to  be 
the  only  one  who  takes  a  real  interest  and  who  seems  to  have  more 
or  less  definite  policies.  The  Trustees  of  his  own  hospital  and  of 
other  hospitals  are  beginning  to  lean  on  him.  His  is  the  greatest 
influence  on  the  medical  thought  of  this  generation,  and  he  has  won 
a  place  so  that  the  indolent-minded  use  his  ideas  as  "authority." 
When  a  person  reaches  this  stage  of  "authority,"  his  poor  ideas 
do  more  harm  than  his  good  ones  do  good.    The  bad  ones,  stamped 

114 


with  his  name,  become  fortified  for  a  further  time  against  attacks, 
and  even  his  good  ones  stand  in  the  way  of  still  better  ones  which 
some  other  aggressive  mind  is  trying  to  introduce. 

I  pay  Dr.  Cabot  the  compliment  of  saying  that  some  of  his 
ideas  are  worth  attacking,  and  I  find  no  one  else  in  Boston,  except 
Dr.  Washburn,  who  takes  a  vital  interest  in  this  hospital  problem 
and  its  relation  to  medical  practice.  I  believe  that  they  both  desire 
to  find  the  Truth,  and  it  is  my  endeavor  to  attract  their  attention  to 
the  path  where  I  believe  the  trail  lies.  I  bay  at  them,  loudly  enough 
for  every  one  to  hear,  so  that  they  may  lead  the  pack  on  the  right 
scent,  for  they  seem  to  me  to  have  lost  the  trail.  It  would  be  useless 
to  talk  to  them  individually,  for  they  are  both  partisans  and  leaders. 
Such  men  are  strong,  because  they  adhere  to  a  purpose  through 
thick  and  thin.  When  their  purpose  is  incorrect,  they  do  more  harm 
than  weak  persons  do. 

They  believe  that  it  is  right  for  them  to  continue  to  use  the 
prestige  of  the  hospital  to  corner  the  "material." 

A  well-endowed  Charitable  Hospital,  with  prestige  and  plenty 
of  material,  can  set  up  "authorities"  and  "specialists"  by  assign- 
ing groups  of  "material"  to  individuals.  They  thus  give  exceptional 
opportunity,  and  exceptional  opportunity  has  a  distinct  money  value 
in  the  Community.  They  can  in  this  way  corner  the  Genito-Urinary 
Surgerj',  the  Gall  Bladder  Surgery,  or  the  Stomach  Surgery  of  their 
neighborhoods.  A  surgeon  who  does  not  have  the  aid  of  the  prestige 
and  opportunity  thus  given  is  at  a  great  disadvantage,  no  matter 
how  able  he  may  be  nor  how  good  results  he  gets  in  the  few  cases 
which  come  to  him.  Should  not  the  recipients  of  these  privileges 
at  least  give  an  account  of  the  cases  entrusted  to  them.''  It  is  unfair 
enough  to  give  special  privilege  to  those  not  qualified,  but  it  is  even 
worse  to  take  away  from  those  who  are  qualified  the  opportunity 
to  benefit  the  patients  and  the  world.  Unfortunately,  today,  it  is 
the  opportunity  which  he  has  at  some  Charitable  Hospital  which 
determines  the  value  of  a  surgeon's  time,  rather  than  the  use  he  has 
made  of  that  opportunity.  As  I  see  it,  the  main  point  on  which  I 
disagree  with  Richard  Cabot  is  as  to  whether  or  not  this  hospital 
opportunity  is  to  be  assigned  by  special  privilege  or  by  fair 
competition. 

I  claim  that  the  End  Result  System  will  tend  to  bring  about 
fair  competition,  and  benefit  alike  the  Patient,  the  Public,  and 
Medical  Science. 

The  Value  of  Surgical  "Material" 

The  following  quotation  from  our  last  Report  seems  worth 
repeating: 

"A  surgeon  needs  at  least  100  operations  a  year  'to  keep  his 
hand  in' — that  is,  to  operate  twice  a  week.  Any  surgeon  can  do, 
and  some  do,  1,000  operations  a  year  and  even  more.  These  are 
about  the  physical  limits,  apart  from  brains.    Therefore,  somewhere 

116 


between  100  and  1,000  operations  will  be  the  best  number  to  get 
the  best  results ;  and  undoubtedly  some  individuals  will  do  better 
work  with  small  numbers,  and  others  with  large  numbers.  For 
Gushing  to  do  100  brain  operations  is  probably  more  than  equiva- 
lent in  time  to  Mayo's  doing  1,000  laparotomies,  yet  to  the  indi- 
vidual the  services  of  both  are  beyond  price.  To  the  ordinary 
practicing  surgeon  who  is  not  a  teacher  or  a  scholar,  there  must  be 
a  mean  between  these  extremes,  varying  with  the  character  of  the 
individual  and  tvpe  of  operation  he  does.  To  do  1,000  operations 
a  year  under  ordinary  circumstances  of  practice  would  leave  a  man 
hardly  any  time  (or  inclination)  for  study  or  research;  to  do  100 
might  leave  him  too  much.  Doing  over  1,000  would  mean  doing 
some  badly,  even  if  the  operator  were  a  very  strong  man.  Doing  less 
than  100  would  soon  mean  too  little  experience  and  skill.  Perhaps 
300,  with  300  working  days,  would  give  the  highest  percentage  of 
satisfactory  results.  Let  us  throw  in  100  for  charity  and  do  200 
for  a  living. 

200  at  $100  =         $20,000  a  year 

200  at  $200  =         $40,000 

200  at  $500  =      $100,000 

200  at  $1,000  =       $200,000 

1,000  at  $100  =      $100,000 

1,000  at  $1,000  =  $1,000,000 

Do  these  figures  give  you  some  inkling  of  the  value  of  hospital 
appointments  and  the  necessity  of  a  surgeon's  getting  to  the  point 
of  having  at  least  100  cases  to  keep  his  hand  in?  Do  they  suggest 
the  value  of  hospital  material?" 

I  then  presented  the  following  statement  of  the  fees  I  had 
received  from  the  270  cases  whose  abstracts  appeared  in  the  two 
previous  Reports ;  my  own  fees  only  are  included, — not  those  of 
the  other  surgeons  who  operated  here: 

Cases  paying  less  than  Hospital  Fee^  91 

Cases  paying  Hospital  Fee  only  89 
Cases  paying  E.  A.  C.  less  than  $100  Professional  Fee 

in  addition  to  Hospital  Fee  38 

Cases  paying  from  $]00-$200  and  Hospital  Fee  23 

Cases  paying  from  $200-$300  and  Hospital  Fee  19 

Cases  paying  from  $300-$500  and  Hospital  Fee  10. 


270 


Of  these  cases  T  operated  on  193  myself,  and  received  for  them 
an  average  Professional  Fee  of  $69.36  for  the  operation  and  after- 
care. 

*The  HcBpital  Fee  is  $50.00  for  the  first  wook  and  ?25.oo  for  each  week  thereafter. 

116 


For  the  year  ending  July  31,  1916,  the  following  is  a  similar 
statement: 

Cases  paying  less  than  Hospital  Fee  5 

Cases  paying  Hospital  Fee  only  42 
Cases  paying  E.  A.  C.  less  than  $100  Professional  Fee 

in  addition  to  Hospital  Fee  16 

Cases  paying  from  $100-$200  and  Hospital  Fee  4 

Cases  paying  from  $200— $300  and  Hospital  Fee  4 

Cases  paying  from  $300-$500  and  Hospital  Fee  3 

74 

New  Cases  67 

Re-entries  7 

74 

No  patient  has  been  charged  a  Professional  Fee  of  over  $500, 
no  matter  how  long  his  stay. 

All  of  tliese  fees  were,  of  course,  swallowed  up  in  my  loss. 

The  average  Professional  Fee  for  the  67  cases  on  whom  I  myself 
operated  during  the  last  year  was  $61.12.  Therefore,  I  have  at 
least  succeeded  in  approaching  the  ideal  of  a  "hundred  dollar  hos- 
pital with  a  hundred  dollar  surgeon";  for  whereas  previously  91 
cases  paid  less  than  the  Hospital  Fee,  in  this  last  year  only  5  paid 
less.  Previously,  52  were  charged  more  than  $100,  and  this  last 
year  only  1 1  were  charged  more.  In  other  words,  I  do  less  for 
nothing  and  less  for  exorbitant  prices. 

But  if  I  could  once  establish  a  reputation  that  would  assure  me 
of  10  beds  full  of  "material,"  you  could  see  the  value  of  it. 

The  Concept  of  This  Hospital^ 

This  hospital  assumes  that  the  great  middle  class  of  the  com- 
munity has  now  no  method  of  obtaining  good  surgical  treatment  at 
fixed  reasonable  prices.  Surgery  is  usually  either  hurriedly  done 
at  the  Charitable  Hospitals  for  nothing,  or  done  at  a  relatively  ex- 
orbitant price  by  the  hospital  surgeon  in  private  practice.  We  plan 
to  meet  this  demand  for  good  surgery  at  low  prices. 

The  hospital  assumes  that  any  self-respecting  individual  can 
raise  at  least  $100  for  an  operation,  including  his  board  and  nursing. 
A  man  who  has  not  saved,  or  who  cannot  find  four  friends,  former 
employers  or  relatives,  who  will  lend  him,  $25  apiece,  need  not  mind 
going  to  a  Charitable  Hospital.  (If  any  philanthropist  doubts  this, 
let  me  refer  to  him  all  such  cases  that  come  to  me.) 

The  average  operation  takes  about  three  weeks  of  hospital  care, 
and  we  assume  that  the  $100  is  to  cover  these  three  weeks,  so  that 
we  arrange  $50  for  the  first  week  and  $25  for  each  week  thereafter. 

I  believe  that  I  can  afford  to  run  a  hospital  of  12  beds  and 
charge  only  the  fee  of  $50   for  the  first  week  and  $25  each  week 

'  This  page  is  repeated  from  the  last  Report. 

117 


thereafter  as  a  minimum  price.  I  plan  to  run  the  hospital  on  this 
scale,  with  an  expense  exactly  equivalent  to  that  standard,  and  to 
make  my  own  living  from  what  professional  fees  I  can  obtain  from 
richer  persons,  or  from  operations  outside  the  hospital,  or  from  office 
practice.  The  standard  of  my  hospital  living  and  equipment  will 
be  about  the  same  as  that  of  a  hotel  charging  $25  a  week.  This  is 
good  enough  for  even  rich  people,  and  a  little  better  than  what  the 
medium  classes  have  in  their  own  homes  in  the  city.  Thus,  if  my 
reputation  for  care  and  thoroughness  increased  so  that  10  of  my  12 
beds  averaged  full  with  a  waiting  list,  the  hospital  itself  could  earn 
$17,333.33  per  annum, — for  it  would  take  173^  cases  for  3  weeks. 
For  this  sum,  the  essential  equipment  and  salaries  could  be  main- 
tained on  even  a  better  scale  than  at  present.  This  makes  it  for  our 
interest  and  for  the  patient's  interest  to  shorten  the  convalescence, 
since  room  is  made  for  another  patient;  and  the  more  often  the 
$50  week  is  brought  around,  the  better  for  us.  Then,  too,  it  makes 
it  for  our  own  interest  to  avoid  complications,  for  we  lose  money  by 
having  any  patient  stay  over  three  weeks  on  account  of  complications. 
Another  assumption  is  this:  that  I  personally  can  do  my  best 
work  with  about  12  beds.  A  surgeon  who  operates  for  more  beds 
has  to  neglect  detail  and  turn  over  too  much  to  his  assistants.  One 
who  operates  for  many  less  does  not  keep  his  hand  in. 

Statement  of  Assets  and  Liabilities 
August   1,  1916 


Assets 


Cash  .... 

Accounts  Receivable  . 
Real  Estate  and  Buildings 
Additions  and  Betterments 
Apparatus  and  Instruments 
X-ray  Apparatus 
Furniture  and  Fixtures 


Liabilities 


Accounts  Payable 
Bank   Loans 
First  Mortgage 
Profit  and  Loss 


$1,108.92 
2,367.66 

32,000.00 

5,514.04 

548.09 

1,063.39 

1,729.06 

$44,331.16 

$2,252.96 

14.000.00 

20.000.00 

8.078.20 

$44,331.16 


The  Real  Estate  and  Equipment  of  the  hospital  are  worth  today 
just  about  what  this  statement  shows  —  $32,000.  This  means  that 
if  the  property  were  sold,  the  Profit  or  Loss  would  depend  on  what 
would  be  realized  for  improvements,  furniture,  and  professional 
equipment  for  over  or  under  $8,078.20. 

118 


Now  as  the  hospital  building  is  only  a  modified  apartment  house 
in  a  rather  crowded  part  of  the  city,  it  is  a  decided  contrast  to  the 
marble  halls  and  spotless  corridors  of  our  Charitable  Hospitals. 

However,  can  any  Board  of  Trustees  produce  from  their  hospital 
records  a  consecutive  series  of  major  surgical  cases  which  will  show 
fewer  errors  of  skill,  knowledge,  care,  equipment,  or  surgical  judg- 
ment than  ours  do? 

On  the  principle  of  the  parable  about  the  talents,  have  the 
Trustees  of  the  Peter  Bent  Brigham  Hospital  done  a  proportionate 
amount  more  with  their  $6,612,679.77,  or  the  Massachusetts  General 
Hospital  with  their  $8,405,874.72,  than  I  have  with  this  $8,078.20? 

Receipts  and  Expenditures 
August  1,  1911,  to  August  1,  1915 

Receipts 


Hospital  Fees    ...... 

$21,515.46 

Board  Special  Nurses  and  Guests 

1,408.32 

Professional  Fees       ..... 

13,387.06 

Rents  and  Miscellaneous  Revenue 

1,541.99 

Loss 

3,367.94 

$41,220.77 

Expenditures 

Running  Expenses $31,994.85 

Interest      ...... 

3,630.12 

Uncollectable  Accounts 

1,062.15 

Doubtful  Accounts    .... 

725.60 

Depreciation  Apparatus  and  Instruments 

204.25 

Depreciation  Furniture  and  Fixtures 

600.50 

Depreciation  Real  Estate  and  Buildings 

880.00 

Depreciation  Additions  and  Betterments 

94.68 

Maintenance  Real  Estate  and  Buildings 

2,128.62 

August  1,  1915,  to  August  1,  1916 
Receipts 


Hospital  Fees    .... 
Board  Special  Nurses  and  Guests 
Professional   Fees 
Rents  and  Miscellaneous  Revenue 
Loss  ..... 


Expenditures 
Running  Expenses     .... 

Interest      ...... 

Depreciation  Real  Estate  and  Buildings 
Depreciation  Additions  and  Betterments 


119 


$41,220.77 


$6,840.02 

443.00 

3,418.54 

736.26 

2,216.60 

$13,654.42 

$11,869.02 

1,541.72 

220.00 

23.68 

$13,664.42 


As  raav  be  seen  in  the  first  statement,  my  loss  for  running  the 
hospital,  including  my  Professional  Fees,  in  the  first  four  years  was 
$3,367.91.  In  this  last  year  alone  (owing  largely  to  the  hospital's 
having  been  closed  for  two  months)  it  was  $2,216.60.  This  means 
that  in  five  years  I  have  lost  $5,584.54  and  a  fraction  of  my  labor. 
All  the  professional  fees  I  have  made  here  have  been  used  to  pay 
the  expenses  of  my  5^  empty  beds.  If  these  beds  had  been  full  of 
Hospital  Fee  cases  paying  only  their  board,  I  should  have  been 
able  to  put  my  professional  fees  in  the  bank.  Or,  if  some  one  should 
endow  my  5^  empty  beds,  it  would  be  equivalent  to  giving  me  a 
position  at  a  Charitable  Hospital,  and  I  should  begin  to  make 
a  profit ! 

But,  after  all,  I  have  lost  only  $1,116.91  a  year,  and  have  not 
worked  any  harder  than  I  used  to  for  the  cases  under  my  care  at 
the  Massachusetts  General.  $1,116.91  is  not  much  more  than  the 
hospital  surgeons  spend  eacii  year  on  new  automobiles,  so  as  to 
appear  successful  and  ready  to  make  the  quickest  time  to  any  mem- 
ber of  a  millionaire's  family  who  happens  to  have  appendicitis. 
I  am  quite  willing  to  pay  $1,116.91  a  year  to  force  the  End  Result 
System  on  these  Hospital  Surgeons,  because  I  rely  on  my  own 
results  to  give  me  the  position  to  which  I  am  entitled.  In  the  mean- 
time, I  am  paying  the  price  of  $1,116.91  a  year  for  remaining  in 
the  market  as  a  surgeon. 

Competition  with  the  Charitable  Hospitals 

A  surgeon  who  is  fortunate  enough  to  have  a  good  hospital 
appointment  can  get  his  100  operations  to  keep  his  hand  in  very 
conveniently;  but  a  surgeon  like  myself,  who  does  not  possess  a 
hospital  position,  must  find  other  means.  He  can  run  a  private 
hospital  as  I  do,  where  he  can  do  operations  for  nothing  without 
loss  of  time,  or  he  can  dash  about  to  such  private  hospitals  as  take 
patients  for  small  fees,  and  to  the  homes  of  patients  who  refuse 
to  go  to  hospitals.  To  get  his  experience,  he  must  bear  the  inevi- 
table financial  loss  on  his  private  hospital,  or  the  inevitable  loss 
of  time  in  going  from  one  hospital  or  house  to  another  to  attend 
scattered  patients.  And  he  must  take  the  responsibility  and  indi- 
vidual care  of  these  patients,  which  is  far  more  time-consuming  than 
a  hospital  visit. 

I  say  inevitable  financial  loss  for  the  private  hospital,  because 
the  Charitable  Hospitals  spend  on  their  patients  an  amount  that  is 
prohibitory  for  a  poor  patient  to  pay  at  a  private  hospital.  Thus 
at  the  Massachusetts  General  Hospital,  in  1915,  $21  a  week  was 
spent  on  each  patient.  In  1915,  the  Peter  Bent  Brigham  spent 
$31.22.  And  tlicse  hospitals  pay  nothing  for  taxes,  very  little  for 
nurses,  and  no  interest  for  invested  capital.  I  must  give  what  they 
give  and  collect  from  the  patient  before  I  can  begin  to  make  a  profit. 

This  means  that  a  surgeon  having  the  privilege  of  operating  at 
these  places,  has  a  hospital  run  for  him  which  is  better  than  any 

120 


private  hospital  within  the  means  of  most  wage-earners.  His 
patients  have  the  benefit  of  free  consultation  in  all  the  other  de- 
partments ;  he  has  the  assistance  of  a  large  and  selected  Junior  Staff, 
who  relieve  him  of  many  detailed  responsibilities ;  and  he  has  labo- 
ratories, libraries,  and  every  possible  facility  under  the  same  roof. 
His  money  is  saved,  his  time  is  saved,  he  can  take  vacations  or  visit 
otiier  clinics  when  he  wants  to,  and  he  has  many  other  advantages 
which  tlie  independent  surgeon  has  not, — particularly  in  less  risk 
of  capital. 

Is  it  too  much  for  the  Trustees  to  ask  him  to  fill  out  an  End 
Result  Card  for  each  patient?  Should  he  have  the  privilege  of 
operating  on  any  more  cases  than  he  can  carefully  study,  follow, 
and  make  sure  of  relieving?  Should  the  type  of  man  who  never 
records,  analyzes,  or  formulates  principles,  be  permitted  to  do 
experiments  for  his  own  advantage  on  the  rare  or  difficult  cases 
which  he  is  unwilling  to  study  and  record  in  detail?  Even  if  he  does 
study,  investigate,  and  write  books,  should  he  still  have  these  privi- 
leges, unless  this  study  fits  him  to  cure  his  patients,  and  he  proves 
that  he  can  and  does  cure  them? 

The  funds  left  to  a  hospital  for  the  sick  poor  are  abused,  when 
they  are  helping  the  hospital  to  compete  with  private  practitioners 
for  curable  patients  able  to  pay,  unless  they  are  first  used  to  prove 
that  the  hospital  itself  gets  standard  results.  Some  of  these  funds 
could  be  more  properly  used  to  analyze  the  Product  of  the  Hospital, 
to  see  whether  the  quality  of  the  work  of  its  staff  is  so  much  better 
than  that  of  the  average  practitioner,  that  it  is  better  for  the  public 
to  force  the  latter  to  the  wall. 

The  financial  report  of  my  hospital  for  five  years  is  evidence 
that  I  alone  cannot  compete  with  the  Charitable  Hospitals,  and  the 
Case  Report  is  equally  good  evidence  that  I  do  my  work  as  well  or 
better.  I  cannot  make  a  living,  unless  in  the  future  I  combine  with 
other  physicians,  surgeons,  and  specialists;  capitalize;  build  and 
equip  a  large  hospital ;  and  force  the  cliques  who  run  the  Charitable 
Hospitals  out  into  the  open,  so  that  the  Public  can  compare  our 
results.  And  to  begin  such  a  combination,  we  shall  have  to  assume 
the  legal  responsibility  for  carelessness  which  is  now  evaded  by  the 
Charitable  Hospitals,  and  which  still  further  increases  our  handicap. 

But  if  this  is  the  only  way  to  make  an  honest  living  in  surgery, 
we  shall  have  to  do  it.  We  are  not  going  to  give  up  surgery  because 
the  Charitable  Hospitals  compete  with  us,  but  we  shall  be  glad  to 
retire,  if  they  can  prove  that  they  deliver  better  goods  to  the  Public 
at  as  reasonable  prices.  When  the  results  of  open  competition  begin 
to  be  published.  Clinical  Science  will  be  able  to  divorce  Hypocrisy, 
and  Commercialism  will  not  pose  as  Charity. 

Here  I  am  with  a  good  surgical  education,  ready  and  willing 
to  give  ray  surgical  services  to  the  poor  (for  the  sake  of  keeping  my 
hand  in  and  my  reputation  good),  and  I  am  not  offered  an  appoint- 
ment at  a  large  Charitable  Hospital.     Having  once  resigned  from 

121 


the  Massachusetts  General  Hospital  as  a  protest  against  the  Senior- 
ity System,  I  am  as  isolated  as  though  I  had  come  from  another  city. 
I  charge  that  it  would  be  as  difficult  for  a  good  surgeon  from  another 
city  to  get  an  appointment  on  the  staff  of  a  Boston  hospital  as  it 
would  for  a  camel  to  enter  the  eye  of  a  needle.  But  it  may  be  said 
that  a  rich  man  might  encompass  both,  although  doubtless  he  can- 
not enter  the  Kingdom  of  Heaven  even  by  endowing  charitable 
institutions. 

A  rich  man  could  have  a  needle  made  so  large,  that  a  camel  could 
enter  its  eye ;  and  he  could  also,  as  I  will  show,  erect  a  competitive 
hospital  in  Boston  which  on  a  "No  Cure,  No  Pay"  basis  would  take 
the  rich  Back  Bay  business  away  from  the  staffs  of  our  Charitable 
Hospitals,  so  that  appointments  on  their  staffs  would  be  so  little 
in  demand  that  the  Trustees  would  be  glad  to  give  him  one. 

If  each  reader  of  this  Report  will  lend  me  $1,000  at  5  per  cent 
interest,  I  will  prove  that  this  can  be  done.  Ten  thousand  copies 
of  this  Report  will  be  sent  out;  each  will  be  read  by  several  readers, 
but  I  do  not  care  for  more  than  10,000  loans.  This  will  give  me 
$10,000,000,  which  will  be  enough  to  start  with.  I  will  then  organ- 
ize as  follows  (for  it  will  be  necessary  to  compete  with  the  actually 
good  organizations  of  the  Mayo  Clinic  and  Battle  Creek  Sanitarium, 
as  well  as  with  the  local  impression  that  the  Boston  Charitable 
Hospitals  and  the  Professors  of  the  Harvard  Medical  School  are  all 
they  should  be,  without  any  End  Result  System) : 

I  shall  advertise  extensively  to  the  laity — 

"Codman  Hospital;  Capitalization,  $10,000,000;  No  Cure,  No 
Pay.  All  kinds  of  operations  done  which  are  likely  to  result  favor- 
ably. We  are  legally  liable  for  carelessness  resulting  in  injury. 
Fixed  Fee,  not  over  $150  for  two  weeks.  (Half  the  fee  may  be  paid 
on  the  instalment  plan.)  We  will  not  treat  you,  unless  we  can  find 
out  what  the  trouble  is,  and  unless  we  believe  we  can  give  you  relief 
for  at  least  a  year.  Send  for  our  End  Result  Report,  which  tells 
what  we  can  and  what  we  cannot  do,  and  illustrates  how  we  shall 
report  your  case.  Do  your  share  to  help  make  the  practice  of 
medicine  a  science.  If  we  refuse  to  accept  your  case,  you  may  have 
our  hospital  services  at  half  price,  provided  you  have  your  own 
professional  attendant  and  guarantee  us  an  End  Result  report  each 
year  later.    We  will  help  you  to  select  a  specialist. 

"Any  physician  or  surgeon  can  treat  his  patients  here  at  half 
price,  provided  he  will  allow  us  to  make  a  record  examination  of 
his  patient  before  treatment,  and  again  a  year  later.  You  will  thus 
insure  your  own  safety  by  putting  your  case  on  record  with  us.  If 
you  can  afford  to  take  the  risk  of  being  operated  on,  your  surgeon 
can  afford  to  take  the  risk  of  stating  publicly  whether  he  relieved 
you  or  not." 

Just  as  will  be  done  in  this  little  hospital,  so  a  big  hospital  might 
divide  its  fees  or  its  income  from  endowment  into  lay  and  profes- 
sional,   and    standardize    both.     The    professional    expense    should 

122 


certainly  equal  the  hospital  expense,  but  at  present  I  have  to  throw 
in  my  professional  labor  on  account  of  my  competitors,  the  Chari- 
table Hospitals.  In  this  hospital,  I  have  to  use  my  judgment  in 
proportioning  expenditure.  If  I  give  larger  nursing  salaries,  I  must 
give  less  expensive  food  or  compensate  by  economizing  on  some 
other  item.  The  prevention  of  waste  and  the  judgment  of  the  pro- 
portion which  each  item  should  take,  in  order  to  be  sure  of  a  product 
— the  satisfied  and  relieved  patient — is  the  essence  of  good  hospital 
management. 

This  idea  of  proportioning  the  expenditure  to  the  items  necessary 
to  obtain  a  perfect  product  has  never  penetrated  hospital  manage- 
ments. Their  minds  have  been  satisfied  with  treatment,  not  with 
the  good  results  of  treatment.  The  appended  table  shows  how  the 
expenditures  were  proportioned  in  this  hospital  (from  August  1, 
1915,  to  August  1,  1916)  and  in  the  Peter  Bent  Brigham  Hospital 
(from  January  1,  1915,  to  January  1,  1916.) 

COMPARISON   OF   PERCENTAGES   OF  VARIOUS   ITEMS   OP 

EXPENSE  OF   PETER   BENT  BRIGHAM   HOSPITAL 

AND  CODMAN  HOSPITAL 

Briohau 

(Salaries 074,8  1 
Office  Expenses 0088  I   ,„.^ 
Telephone 0082  f  •■'"*" 
Misc 0122  J 


Prof.  Care 

of 
Patients 


Dept. 
Expenses 


House  and 

Property 

Expenses 

Items  not 
Compa- 
rable 


f  Nurses 1236  1 

Ward  Employees 0145 

Apparatus  and  Instruments  .  .  .0128 
Medical  and  Surgical  Supplies  .  .0503 
Alcohol,  Wines,  and  Liquors      .     .     .0015 

X-ray 0404 

Outpatient  Dept 0228 

Salaries 0815 

Supplies 0252 

Laundry 0203 

Bread 0084 

Dairy  Products 0642 

Groceries 0204 

Fruit  and  Vegetables 0184 

Meat,  Poultry,  and  Fish 0598 

Water 0073 

Heat,  Light,  and  Power 1282 

Insurance 00.34 

Maintenance  Real  Est.  and  Bldgs.     .0518 

Taxes  and  Interest 

Janitor 

Physicians,  Surgeons,  Orderlies  .  .0978 

Druggists,  Clerks,  etc 0086 

Ambulance .0348 


.2659 


.2982 


,1907 


M412 


CoDMAN 

.0574  ] 

.0074 

.0195 

.0667 

.1629 

.0251 

.0047 

.0345 

.0031 

.0092 

.0224 

.0696 

.0176 

.0348 

.0038 

.0452 

.0276 

.0264 

.0469 

.0049 

.0635 

.0074 

.0381 

.1669 

.0344 


1610 


V  .2619 


)■  .2719 


.1139 


.2013 


100%  100%   100%  100% 

Explanation :  These  fiprures  are  the  percentapres  of  each  item  to  the  total  expense  of  each 
institution.  Notice  the  remarkable  similarity.  I  have  to  provide,  administer,  and  sell  all  of 
these  thing's  before  I  can  make  a  cent.  The  so-called  Charitable  Hospital  provides  all  this  for 
thesursreoii  and  assures  him  of  plenty  of  practice,  all  the  prestipe  thev  can  Kivehim.anda 
fee  besides  (if  one  can  be  obtained) ;  and  yet  the  Trustees  take  no  Inventory  of  his  Product. 

123 


This  table  gives  the  proportions  of  expenditure  for  treatment, 
but  not  for  product  in  the  form  of  relieved  and  cured,  or  even 
cared-for  cases.  To  make  a  proper  balance  sheet,  the  case  reports 
of  the  two  hospitals  should  be  presented.  The  product  could  then 
be  compared  in  quantity  and  in  quality.  One  of  Cushing's  successful 
brain  cases  would  be  like  a  priceless  painting,  incomparable  in  value 
with  any  of  my  cases ;  but  a  successful  inguinal  hernia  would  be  no 
better  at  the  Brigham  than  at  this  hospital.  It  would  merely  be  an 
ordinary  commercial  article,  requiring  so  much  capital  and  labor 
for  its  making. 

If  the  professors  of  our  medical  schools  and  the  appointees  of 
our  large  hospitals  want  the  loyal  support  of  the  pupils  they  have 
sent  out  into  practice,  they  must  not  compete  with  them  for  simple 
curable  cases. 

We,  the  practicing  surgeons  and  physicians  of  the  Community, 
are  glad  to  have  the  leaders  of  the  profession  given  every  oppor- 
tunity for  study  and  research,  so  that  they  can  make  the  most  of 
their  natural  gifts  and  ambition.  We  want  to  have  somebody  to 
turn  to  when  we  are  in  doubt  of  our  diagnosis  or  of  our  qualifications 
to  give  successful  treatment.  We  want  to  see  them  get  large  fees 
for  opinions  or  services  to  which  their  careful  study  or  unusual 
success  in  special  forms  of  treatment  has  entitled  them.  We  are 
even  willing  to  give  up  our  own  fees  in  unusual  poor  cases,  so  that 
what  little  money  there  is  can  go  to  the  great  man,  in  return  for 
the  time  he  has  snatched  from  his  studies. 

But  what  we  are  tired  of  is  this:  of  seeing  the  prestige  of  the 
hospitals  and  the  medical  schools  used  by  some  members  of  their 
staffs  to  line  their  own  pockets,  and  to  help  them  pose  as  experts 
on  things  in  which  they  are  no  more  expert  tlian  we  are.  We  don't 
wish  to  see  the  time  which  is  saved  for  these  men  by  their  hospitals, 
their  assistants,  their  patients,  and  their  consultants  used  entirely 
to  make  more  money.  We  want  real  contributions  to  medical  science, 
real  public  demonstrations  of  new  methods  advantageous  for  us  to 
use,  real  efforts  to  manage  our  medical  organizations,  and  real 
protection  of  our  legitimate  interests  in  public  matters  and  legisla- 
tion. We  are  tired  of  being  criticized  by  men  safely  ensconced 
behind  tlie  academic  fortifications  and  bulwarks  of  hospital  prestige. 
We  want  honest  End  Result  Reports  of  these  hospital  cases  which 
we  send  in  to  them. 

We  believe  that  natural  qualifications,  industry  in  study  and 
experiment,  opportunity,  and  practical  experience  have  to  be  com- 
bined in  judicious  proportions  to  make  the  unusual  teacher  and 
leader.  We  practitioners  ourselves  have  some  claim  to  all  of  these 
things,  with  perhaps  an  excess  of  practical  experience  crowding  out 
study;  but  still  we  are  constantly  learning  things  which  the  hospital 
professor  never  knows,  and  we  resent  his  criticism  of  our  habits 
and  customs  in  the  struggle  for  existence. 

Let  him  tell  us  what  his  own  results  are.     If  his  results  are  better 

121 


than  ours,  we  will  ask  him  to  show  us  his  methods;  but  first  we 
want  to  be  convinced  that  his  knowledge  and  study  are  really  more 
efficient  than  our  individual  experience.  As  far  as  we  can  see,  the 
cases  which  we  cannot  relieve,  and  which  we  send  to  his  hospital, 
are  occasionally,  but  not  always  relieved.  He  is  welcome  to  what  we 
cannot  cure  or  relieve,  but  we  resent  his  taking  his  valuable  time 
(just  to  increase  his  income)  to  treat  cases  which  we  can  handle 
successfully  ourselves — just  as  satisfactorily  and  with  less  cost  to 
the  patient.  He  is  welcome  to  our  difficult  cases,  and  we  are  glad 
to  give  him  the  credit  when  he  can  cure  them. 


BALANCE  SHEET  OF  THE  COMMERCIAL  SURGEON 
AND  HIS  CONSCIENCE 


Credit 

No  obligation  to  study,  teach,  inves- 
tigate, and  record,  except  in  so  far 
as  such  effort  may  enlarge  the 
scope  of  his  business. 

The  opportunity  to  select  his  col- 
leagues and  assistants,  and  to  co- 
operate with  them  for  the  common 
purpose  of  making  his  institution 
a  success. 

Freedom  to  refer  to  others: 
Difficult  and  troublesome  cases. 
Cases  who  cannot  pay. 

A  free  conscience  in  undertaking 
only  work  he  is  qualified  to  do, 
without  being  obliged,  as  in  ordi- 
nary practice,  to  make  all  kinds  of 
goods  for  the  buyers  who  stray 
into  his  hands  for  articles  which  he 
has  had  no  training  in  making. 

The  opportunity  to  advertise  the 
goods  he  is  in  a  position  to  deliver. 


Debit 
Being  obliged  to  take  so  much  of  his 
time  for  administration,  petty  de- 
tails, and  economies,  that  he  has 
little  opportunity  for  study,  travel, 
and  the  pursuit  of  further  knowl- 
edge. 

The  necessity  of  active  competition 
to  retain  his  practice  and  keep  his 
hospital  beds  full,  so  that  he  does 
not  lose  as  well  as  fail  to  gain 
money. 

Constant  watchfulness  to  avoid  errors 
which  might  lead  to  loss  of  pres- 
tige for  his  hospital,  or  even  to 
loss  of  his  private  fortune,  from  a 
just  or  unjust  legal  decision. 

The  necessity  of  keeping  his  fees  low, 
because  (if  he  is  honest)  he  must 
always  admit  that  if  a  person  has 
money,  he  can  afford  the  services 
of  those  Hospital  Surgeons  whose 
opportunities  are  greater  than  his 
for  any  particular  class  of  cases. 

The  loss  of  pride  in  saying  to  his 
patient,  "Your  case  is  too  difficult 
for  me — go  to  Dr.  So-and-So." 

Being  subject  to  pay  the  price  of 
advertising — litigation  for  care- 
lessness; in  other  words,  to  risk 
his  capital. 


To  which  side  shall  we  add  the  End  Result  System?  For  this  hospital 
it  is  distinctly  on  the  credit  side, —  for  it  is  the  purpose  of  this  hospital  to 
force  it  on  the  Charitable  Hospitals.  But  when  the  day  comes  (as  it  must, 
in  justice)  when  it  is  legally  enforced  on  all  hospitals,  the  Commercial 
Hospital  will  put  it  in  the  Debit  column. 


125 


BALANCE   SHEET   OF  THE   HOSPITAL  SURGEON 

AND  HIS  CONSCIENCE 

Credit  Debit 


Having  all  the  hospital  expense  given 
by  tiie  endowment. 

Having  all  the  administrative  work 
done  for  him. 

Having  most  of  the  details  of  physi- 
cal examination,  laboratory  tests, 
dressings,  visits,  and  after-care 
done  by  subordinates. 

Being  relieved  of  many  interviews 
with  friends  and  relatives  in  per- 
son and  on  the  telephone. 

Being  able  to  use  the  time  saved  in 
these  things  for  study  and  visits  to 
other  clinics. 

Freedom  to  experiment  without  much 
medico-legal  responsibility. 

The  acknowledged  right  to  charge 
rich  persons  large  fees,  because  of 
his  unusual  opportunity  to  become 
truly  expert. 

Having  access  to  well-equipped  li- 
braries and  laboratories,  and  to 
the  assistance  and  advice  of  col- 
leagues. 

Having  his  advertising  done  for  him 
by  the  ever-changing  stream  of 
assistants,  students,  nurses,  col- 
leagues, visiting  physicians,  and 
visiting  medical  societies,  which 
day  after  day,  week  after  week, 
and  year  after  year  pours  steadily 
through  the  hospital. 


The  obligation  to  make  the  most  of 
his  opportunities. 

The  obligation  to  teach  his  students 
and  subordinates. 

The  obligation  to  be  ever  watchful 
for  the  errors  of  subordinates  over 
whose  appointment  he  has  only 
partial  control. 

The  obligation  to  keep  up  to  date 
with  progress  by  reading,  investi- 
gating, etc. 

The  obligation  to  cooperate  with  col- 
leagues (who  are  sometimes  un- 
congenial). 

The  obligation  to  experiment. 

The  obligation  to  set  an  example  to 
the  students  who  must  get  their 
living  by  the  practice  of  medicine. 

The  obligation  to  take  cases  as  they 
come,  without  selection — usually 
tlie  riffraff  of  society,  or  the  most 
obstinate  and  difficult  diseases  to 
treat. 

The  obligation  to  take  an  active  part 
in  local,  state,  and  national  medi- 
cal societies. 

The  obligation  to  see  that  each  case 
under  his  care  receives  attention 
and  his  best  skill. 


To  which  side  shall  we  add  the  End  Result  System?  Does  he  prefer  to 
be  known  for  what  he  can  do,  or  for  what  he  appears  to  be  doing,  says  he 
can  do,  and  teaches  should  be  done?  When  all  hospitals  are  obliged  to  add 
the  End  Result  System,  he  will  put  it  in  the  Credit  column. 


Cheap  Operations 
Since  I  have  a  lO-bed  hospital,  and  have  been  able  to  keep  only 
4^  beds  full  on  the  average;  since  my  minimum  professional  fee  is 
zero;  since  I  actually  pay  more  for  expenses  than  I  charge  for 
board,  it  follows  that  I  am  anxious  to  get  patients  to  operate  on. 
My  services  have  become  cheap;  for  I  must  be  doing  surgery,  to 
continue  to  pose  as  a  surgeon.  Unless  I  have  at  least  a  hundred 
operations  a  year,  I  must  fall  in  the  race,  or  else  pretend  to  be  what 

126 


I  am  not.  It  is  no  charity  for  me  to  do  these  operations ;  in  fact, 
if  I  could  pay  some  hospital  $10  apiece  to  let  me  do  a  hundred 
operations  a  year,  it  would  be  less  expensive  for  me  than  it  is  at 
present. 

But  am  I  really  in  any  different  position  from  that  of  my  com- 
petitors in  this  respect.''  Their  services  have  also  become  cheap. 
They  must  go  to  the  Charitable  Hospitals,  and  pretend  that  their 
services  are  in  demand.  They  have  become  dependent  on  these  hos- 
pitals for  their  reputations;  if  they  lost  their  appointments,  most 
of  them  could  not  even  run  a  little  hospital  like  this.  They  go  about 
to  little  hospitals,  operating  for  nothing,  with  a  pretense  of  kind- 
ness. The  truth  is,  their  services  have  become  cheap.  The  Chari- 
table Hospital  system  has  been  run  into  the  ground,  and  surgery 
has  become  cheap, — so  cheap,  that  the  whole  Community  suffers 
from  it. 

The  supply  of  mediocre  surgeons  far  exceeds  the  demand  for 
their  services.  Each  charges  a  few  wealthy  patients  for  many 
operations  on  poorer  ones,  and  the  charge  is  governed,  not  by  the 
quality  of  the  services  rendered,  but  by  the  pocketbook  of  the  patient. 

No  one,  be  he  rich  or  poor,  knows  whether  he  really  has  the 
services  of  a  good  surgeon.  This  is  because  our  Charitable  Hos- 
pitals, which  could  do  so,  do  not  find  out  which  surgeons  get  the 
best  results,  and  let  the  public  know.  A  person  should  be  sus- 
picious of  a  surgeon  who  will  operate  on  him  for  nothing.  No  opera- 
tion should  be  done  for  nothing,  even  at  a  Charitable  Hospital, 
because  it  frees  the  surgeon  of  responsibility.  Somebody,  perhaps 
the  Hospital  Funds,  should  pay  for  it  directly,  or  exact  a  sense  of 
responsibility  for  the  result.  Services  that  are  rendered  for  nothing 
are  apt  to  be  cheap. 

The  fact  that  it  is  necessary  for  each  surgeon  to  get  a  hundred 
operations  a  year  has  cheapened  surgery  more  than  surgeons. 

If  a  hospital  hired  its  surgeons,  it  would  not  assign  its  cases 
by  seniority  or  by  the  calendar.  Services  above  the  average  would 
not  be  cheap,  and  the  Community  would  learn  that  certain  opera- 
tions called  for  more  experienced  services  than  others.  Moreover, 
the  Community  would  demand  a  penalty  for  failure  due  to  care- 
lessness. 

It  is  ridiculous  that  I  should  be  unable  to  average  more  than 
$61.12  for  a  major  operation  and  three  weeks  of  after-care!  This 
is  not  enough  to  elicit  a  sense  of  moral  responsibility !  And  yet,  in 
publishing  this  Report  I  take  more  responsibility  than  the  hospital 
surgeons  do. 

The  Value  of  My  Time 

We  are  apt  to  think  of  time  as  if  we  had  plenty  of  it.  As  a 
matter  of  fact,  we  have  only  about  2,000  hours  a  year  of  real  work- 
ing time.  Labor  Unions  and  Efficiency  Experts  alike  recognize  the 
fact  that  long  hours  reduce  the  rate  of  accomplishment  and  the 

127 


quality  of  the  work.  Tliough  opinions  vary  to  a  certain  extent,  we 
may  take  from  the  skilled  workman  the  standard  of  eight-hour  days, 
five  days  a  week,  for  fifty  weeks.  Thus,  8  X  5  X  50  =  2,000  hours 
a  year. 

If  a  skilled  workman  needs  to  conserve  his  energy  for  a  maxi- 
mum output  per  hour,  a  surgeon  certainly  should.  That  a  surgeon's 
hours  are  irregular,  does  not  justify  the  overwork  in  our  hospitals 
(the  overwork  is  not  infrequently  due  to  a  desire  to  corner  "the 
material,"  and  those  that  corner  may  do  it  in  a  hurry)  and  the 
consequent  damage  to  the  "material." 

People  should  certainly  be  willing  to  pay  a  larger  rate  per  hour 
for  skilled  labor  on  their  own  bodies  than  on  metal  and  wood.  One 
dollar  an  hour  is  a  high  wage  for  a  mechanic,  but  no  thinking  man 
would  want  to  pay  less,  even  to  the  mechanic's  helper,  when  his  own 
body  is  the  material.  Yet  few  surgeons  in  their  early  years  can 
sell  their  time  for  as  much  as  this,  and  there  are  few  that  do  not 
work  more  than  2,000  hours.  It  is  several  years  before  a  young 
surgeon  can  get  even  $1  an  hour, —  $2,000  for  the  year.  And  many 
years  before  he  can  count  on  $3  an  hour, —  $6,000  a  year.  My  own 
2,000  hours  have  never  sold  for  over  $5  an  hour, —  $10,000  a  year. 
Yet  I  have  on  several  occasions  received  $1,000  for  a  single 
operation. 

Society  does  not  expect  a  prominent  surgeon  to  go  about  in 
shabby  clothes,  to  run  an  out-of-date  automobile,  or  do  so  much  work 
that  he  is  tired  out  all  of  the  time.  Society  exacts  subscriptions  to 
popular  causes,  wedding  presents,  reciprocative  dining;  attendance 
at  funerals,  and  at  social  events.  The  greatest  surgeon  cannot  omit 
some  of  these  things,  if  he  wishes  to  be  known  by  the  people  who 
can  pay  big  fees. 

Today,  in  an  American  city,  he  must  spend  $20,000  a  year,  if  he 
has  a  family.  If  his  share  of  the  world's  work  is  2,000  hours,  you 
must  pay  him  $10  an  hour.  If  he  spends  half  his  time  at  the  Chari- 
table Hospital  and  the  Medical  School,  you  must  pay  him  $20  an 
hour.  When  you  take  fifteen  minutes  of  his  office  hour  talking  over 
your  telephone  about  your  maid,  who  is  under  his  care  at  the 
Charitable  Hospital,  you  owe  him  $5  ! 

I  have  no  charitable  hospital  or  medical  school  to  demand  my 
time,  but  I  have  to  earn  over  $10,000  to  pay  the  expenses  of  this 
hospital  before  I  can  make  a  cent;  so  that  if  I  can  assume  that  I 
must  also  have  $10,000  a  year  to  maintain  my  social  position,  my 
time  is  also  worth  $20  an  hour.  But,  as  a  matter  of  fact,  I  am 
glad  to  work  ovcrhours  at  any  time  for  $5  an  hour!  Surgeons 
that  are  any  good  are  always  working  overtime  —  sometimes  double 
time  —  on  account  of  the  competition.  This  is  another  abuse  of  the 
Cliaritable  Hospital  System,  which  does  not  separate  the  wheat 
from  the  chalf.  If  the  able  surgeons  were  allowed  to  excel,  they 
would  not  have  to  work  overtime. 

128 


I  should  like  to  have  a  large  salary  or  earn  a  large  amount  of 
money.  Why,  if  I  admit  that  I  really  don't  need  it?  I  am  com- 
fortably off,  and  what  I  want  is  time  to  get  to  the  woods  and 
streams.  But  read  the  "Surgeon's  Reward"  (page  135).  I  should 
miss  the  daily  flattery  of  my  successful  cases — and  commendatory 
letters  about  the  End  Result  System.  I  want  more  money,  so  that 
I  can  spend  more  on  my  hobbies.  I  want  more  cases  to  keep  my 
hospital  full,  so  that  I  can  keep  on  putting  numbers  on  the  chart 
and  scoring  them  with  red  ink,  to  show  that  they  were  good  products. 
I  want  new  kinds,  so  that  I  can  put  them  in  the  spaces  that  have 
no  numbers,  just  as  I  used  to  put  stamps  in  my  stamp  book, — not 
printed  counterfeits. 

I  know  that  I  shall  die  unsatisfied,  with  many  spaces  empty  or 
not  scored  as  perfect.  I  know  that  some  day,  in  order  to  keep  the 
successful  spots  coming  on  the  chart,  I  shall  have  to  ask  others  to 
do  the  operations  and  see  them  get  the  grateful  looks. 

The  Value  of  An  Operation 

There  are  certain  conditions  under  which  an  operation  will  save 
life.  The  financial  value  of  such  an  operation  will  depend  to  a 
certain  extent  on  how  much  the  person  who  pays  the  bill  values 
the  life  that  is  saved.  It  depends  on  whether  it  is  your  own  life 
(and  how  much  you  enjoy  it),  your  wife's  life  (and  how  much  you 
care  for  it),  or  some  "poor  relation's"  life  (and  how  worthless 
you  think  it  is). 

From  this  point  of  view,  one  can  see  how  hospital  Trustees  value 
their  patients'  lives,  for  they  do  not  pay  the  surgeon  for  the  opera- 
tion. On  the  contrary,  they  pay  the  surgeon  by  the  opportunity 
to  do  the  operation. 

The  same  may  be  said  of  those  operations  which  do  not  save  life, 
but  merely  relieve  suffering.  Most  persons  value  an  operation  which 
relieves  their  suffering  more  than  one  which  saves  their  life.  And 
they  value  the  relief  of  the  suffering  of  their  poor  relations  —  some- 
what, but  not  much. 

And  Trustees  of  hospitals,  as  a  rule,  value  the  relief  of  the 
sufferings  of  their  patients  so  little,  that  they  do  not  even  insist 
on  following  up  their  patients  to  see  whether  their  sufferings  are 
relieved. 

Nevertheless,  one  hears  of  enormous  fees  being  paid  for  opera- 
tions.   Why  should  one  surgeon  get  a  higher  fee  than  another? 

The  best  operator  in  the  world  is  undoubtedly  a  better  operator 
than  I  am,  but  what  is  the  money  value  of  the  difference,  when  it 
comes  to  a  single  operation  on  an  individual  patient? 

I  have  done  about  3,000  operations  to  his  (perhaps)  30,000. 
Yet  to  an  individual  patient,  what  difference  would  there  be  in  the 
chances?  I  have  done  perhaps  300  interval  appendectomies  without 
a  fatality,  and  he  has  done  perhaps  3,000  (with  probably  one  or 
two  fatalities).    For  other  kinds  of  routine  operations  I  can  make 

129 


the  same  boast.  "What,  then,  is  the  financial  value  of  the  difference 
in  risk  in  my  hands  or  his  ? 

But  consider  those  grave  cases  listed  on  pages  143-155.  It  is 
in  such  cases  that  the  difference  would  show.  Undoubtedly  he  would 
have  saved  some  of  those  cases,  and,  if  there  is  a  difference  in  value 
between  our  services,  it  would  be  shown  by  the  proportion  Avhich 
he  would  have  saved.  He  might  have  saved  5  per  cent,  10  per  cent, 
or  50  per  cent,  but  the  value  of  his  services  compared  to  mine  would 
vary  with  this  percentage — but  only  in  these  extremely  sick  cases. 

If  you  needed  an  operation,  you  might  be  willing  to  pay  $1,000 
more  for  a  1  per  cent  better  chance,  but  how  much  more  are  you 
willing  to  pay  for  an  increased  1  per  cent  chance  in  the  case  of  your 
poor  relation? 

The  Trustees  of  the  Massachusetts  General  Hospital  showed 
their  interest  in  their  patients  by  allowing  me  to  operate  on  that 
list  of  cases  when  I  was  first  appointed  on  their  Staff, —  and  you  will 
find  the  same  state  of  affairs  in  almost  all  the  large  hospitals  in 
this  country. 

The  difference  in  surgeons'  results  is  not  as  demonstrable  as  in 
their  incomes.  When  you  pay  a  high  price  for  an  operation,  you 
pay  not  according  to  the  value  of  the  operation  to  you,  nor  accord- 
ing to  the  difficulty  of  the  operation,  nor  according  to  the  real  ability 
of  the  surgeon,  but  according  to  the  relation  of  the  surgeon's  repu- 
tation and  your  own  bank  account. 

The  proper  way  to  pay  for  a  successful  operation  is  to  pay  the 
surgeon  a  reasonable  sum  for  his  expert  labor,  and  then  give  a  large 
sum  to  some  endowed  institution  for  the  advancement  of  surgical 
science.  You  owe  much  more  to  surgical  science  than  you  do  to  the 
surgeon. 

Has  This  Hospital  Been  a  Success? 

A  Success  is  the  attainment  of  an  object.  The  main  object  of 
this  hospital  has  been  to  force  the  great  Boston  Hospitals  affiliated 
with  the  Harvard  Medical  School  to  adopt  the  principles  of  the 
End  Result  System. 

It  was  necessary  to  demonstrate  the  feasibility  of  this  End 
Result  System,  so  that  Trustees  who  must  always  be  conservative, 
may  have  an  example  to  follow.^ 

It  was  necessary  to  demonstrate  that  the  Public  are  willing  to 
have  the  facts  about  their  cases  published  for  the  good  of  others. 

It  was  necessary  to  show  that  surgeons  and  their  consultants 
may  be  willing  to  have  their  failures  and  errors  known. 

It  was  necessary  to  show  that  a  man  who  practices  this  doctrine 
can  make  his  living  and  keep  out  of  the  courts. 

It  will  be  necessary  to  show  that  End  Result  Reports  of  hos- 

'  Trustees  must  avoid  criticism.  At  present  they  would  fear  criticism,  if  they  should 
introfluce  so  radical  a  change.  We  want  to  put  them  in  a  position  where  they  will  fear 
criticism,  unless  they  do  introduce  it. 

180 


pitals  are  of  enough  value  to  the  Medical  Profession  to  pay  for  their 
publication. 

Finally,  it  will  be  necessary  to  prove  that  a  "No  Cure,  No  Pay 
Institution"  can  be  run  on  a  definite  standard  of  fees,  and  be  able 
to  pay  a  dividend  to  its  stockholders.  (See  "The  Dividing  Line 
between  Medical  Charity  and  Medical  Business."  N.  Y.  Med.  Rec. 
May  13,  1916.    By  E.  A.  C.) 

We  believe  that  we  have  demonstrated  all  these  things  except 
the  last  two.  We  admit  that  we  have  not  yet  made  a  financial  suc- 
cess of  the  hospital;  but,  as  shown  in  Part  III,  we  are  now  going 
to  bend  our  energies  to  so  doing. 

Aside  from  these  great  primary  considerations,  are  there  not 
other  respects  in  which  this  hospital  has  been  a  success }  Has  it 
not  furnished  an  opportunity  to  our  employees  to  make  an  honest 
living?  Has  it  not  done  something  in  teaching  all  the  patients, 
doctors,  nurses,  and  employees  who  have  come  into  contact  with 
it  that  a  frank  confession  of  our  ignorance,  and  acknowledgment  of 
our  errors  and  shortcomings,  is  possible  in  surgical  practice.^  Is  it 
not  fair  to  claim  that  its  success  is  in  some  degree  measured  by  the 
facts : 

That  the  Massachusetts  General  and  Peter  Bent  Brigham  Hos- 
pitals in  their  Annual  Reports  now  publish  abstracts  of  the  cases 
which  die  while  under  their  care.'' 

That  an  Abstract  Report  was  made  of  all  the  cases  operated 
on  before  the  Clinical  Congress  of  Surgeons  of  North  America,  at 
its  meeting  in  Boston,  and  that  another  one  is  to  be  made  of  the 
meeting  in  Philadelphia?^ 

That  the  Massachusetts  Medical  Society  now  has  a  Section  on 
Hospital  Administration,  and  has  recommended  uniform  Hospital 
Reports  ? 

That  the  Surgical  Staffs  of  the  New  York  Hospital  and  the 
Presbyterian  Hospital  and  the  University  of  Pennsylvania  Hospital 
hold  weekly  meetings  at  which  the  results  of  their  cases  are  re- 
viewed and  criticized? 

That  the  American  College  of  Surgeons  has  obtained  a  large 
f imd  for  an  investigation  of  hospitals  ? 

And  will  it  not  mean  some  measure  of  success,  if  this  Report 
is  distributed  to  all  the  members  of  the  American  College  of  Sur- 
geons and  to  all  the  members  of  the  Massachusetts  Medical  Society, 
without  the  writer's  receiving  a  vote  of  censure  or  a  request  for 
resignation  from  any  of  the  following  Societies  of  which  he  is  a 
member?  : 

American  Medical  Association.    Society  of  Clinical  Surgery. 
American  College  of  Surgeons.     ^Massachusetts  Medical  Society. 
American  Surgical  Association.    Various  local  medical  societies. 

'  Unless  the  surgeons  of  Philadelphia  are  afraid  to  stand  comparison  with  those  of 
Boston  ! 

181 


Neither  the  Corporation  of  Harvard,  nor  the  Trustees  of  the 
Massachusetts  General  Hospital,  for  Avhom  I  worked  for  years, 
have  ever  sought  my  advice  individually  or  collectively  on  this 
subject.  I  have  never  talked  with  a  Trustee  of  the  Massachusetts 
General  Hospital  on  hospital  matters,  either  before  or  since  my 
resignation.  I  never  knew  one  to  show  the  slightest  interest  in  the 
End  Result  System. 

Yet,  strangely  enough,  I  shall  never  myself  regard  this  hospital 
as  a  success,  until  the  Trustees  of  the  latter  institution  ask  my 
advice  about  something.  So  great  is  the  Conservatism  of  this  Board, 
that  I  am  convinced  that  the  only  way  for  me  to  show  them  anything 
is  to  show  it  first  to  the  rest  of  the  world,  and  then  let  the  rest  of 
the  world  show  it  to  these  Trustees. 

Richard  Cabot  had  to  do  this  with  the  Social  Service  Idea. 

Before  making  a  New  Organization  to  Demonstrate  the  Finan- 
cial Sovmdness  of  the  End  Result  Idea,  it  is  first  necessary  to 
consider 

Why  This  Hospital  Has  Not  Been  a  Financial  Success 

The  following  five  reasons  occur  to  me : 

1.  I  have  exhibited  a  Cartoon  at  a  local  medical  meeting,  and 
in  fact  publicly  alleged: 

That  Harvard  pays  her  medical  teachers  for  the  most  part 
by  opportunity  to  practice  among  the  richer  people  of  the  Com- 
munity,—  the  Back  Bay. 

That  the  large  Boston  Charitable  Hospitals  are  used  as 
experimental  clinical  laboratories  where,  by  cornering  "the  ma- 
terial," the  "Harvard  Ring"  are  able  to  keep  themselves  "the 
best  doctors"  in  our  Community. 

That  they  shirk  the  "End  Result  System,"  although  they 
know  it  to  be  logically  sound,  because  it  is  not  "expedient,"  and 
would  militate  against  the  "Vested  Interests." 

That  it  is  only  fair  for  them,  if  they  claim  superiority,  to 
make  public  the  records  of  their  clinical  experiments,  to  give 
the  rest  of  us  maximum  standards. 

Is  it  any  wonder  that  after  this,  my  former  colleagues  do  not 
patronize  my  hospital .'' 

Do  you  blame  them  for  spreading  and  exaggerating  the  unfor- 
tunate facts  that  I  am  not  a  skillful  operator,  that  I  am  hard  to  get 
along  with,  aggressive,  independent,  idealistic,  and  a  monomaniac 
on  the  End  Result  Idea?  Even  my  friends  damn  me  with  faint 
praise. 

A  surgeon  never  really  knows  how  poor  a  surgeon  he  is.  No  one 
could  have  been  more  surprised  than  I  was,  when  the  Surgical  Staflf, 
the  Executive  Committee,  and  the  Board  of  Trustees  of  the  hospital 
which  I  had  served  for  years  agreed  that  another  surgeon  deserved 
promotion  more  than  I  did.     Even  now  I  am  not  convinced. 

132 


But,  at  any  rate,  the  fact  that  I  was  not  promoted,  is  well  known 
among  any  possible  Back  Bay  consultants  and  among  my  friends 
and  relatives,  most  of  whom  are  well-to-do.  Naturally  they  cannot 
risk  themselves  and  their  families  in  my  care,  when  better  operators 
are  available.  And  besides,  I  will  not  accept  their  cases,  if  they  are 
diflScult,  because  now  I  am  authoritatively  assured  that  I  am  not 
qualified  to  undertake  them. 

2.  But  as  they  have  not  yet  reappointed  me,  and  until  then, 
therefore,  I  have  no  right  to  the  rich  patients,  I  must  lower  my  prices 
and  try  for  those  of  moderate  means.  The  fact  that  I  served  so 
many  years  at  the  Massachusetts  General  without  being  dropped, 
and  that  I  am  still  honored  with  membership  in  the  societies  men- 
tioned on  page  131,  makes  me  feel  justified  in  regarding  myself  as 
at  least  a  mediocre  surgeon. 

But  how  can  I  get  patients  of  moderate  means?  I  meet  in 
competition  the  Junior  hospital  surgeons,  the  assistants  of  the  big 
surgeons,  as  well  as  the  lone  surgical  pirates  who,  without  hospital 
appointments,  do  privateering  and  possibly  fee-splitting. 

Is  it  likely  that  any  of  these  competitors  will  say  a  good  word 
for  me}  They  much  prefer  to  call  in  consultation,  when  they  are 
in  trouble,  the  Big  Hospital  surgeons,  who  believe  that  it  is  right 
for  them  to  "back  up"  consultants  who  have  undertaken  operations 
they  had  no  business  to  do.  As  a  young  surgeon,  if  my  cases  went 
wrong,  it  was  the  man  whose  reputation  would  carry  weight  with 
the  family  that  I  wished  to  help  me  out,  not  the  one  who  would 
put  down  my  error  in  a  book  and  publish  it !  So,  without  advertising 
directly  to  the  patient,  this  hospital  is  not  likely  to  find  many 
consultants.  It  has  been  a  wonder  to  me  that  my  few  faithful  friends 
and  consultants  have  stuck  by  me  so  far.  It  would  only  need  a  few 
more  to  fill  my  beds  and  give  me  power  to  force  the  situation. 

3.  There  are  also,  perhaps,  some  personal  reasons, —  perhaps 
I  have  not  worked  hard  enough,  been  gracious  enough,  or  taken 
enough  personal  interest  in  my  patients.  I  can  only  say  that  I  have 
been  able  to  earn  my  living  outside  the  hospital  and  to  run  the  hos- 
pital fairly  satisfactorily  to  the  patients  (thanks  to  my  Superin- 
tendent, Mrs.  Freeman).  During  the  last  year  there  has  been  a 
total  increase  of  business  of  25  per  cent  over  the  preceding  year 
(1916  over  1915).  This  seems  a  fairly  normal  increase  of  personal 
practice. 

4.  I  have  been  inefficient  in  my  advertising.  My  previous  Hos- 
pital Reports  have  hitherto  brought  me  but  one  case.  My  Reports 
have  been  widely  read,  as  I  know  by  letters  of  congratulation  and 
encouragement,  but  no  patients  are  sent  on  account  of  them.  The 
patients  have  come  from  personal  friends  or  other  patients,  exactly 
the  sources  I  least  approve  of,  as  such  persons  are  least  qualified 
to  judge  of  the  real  efficiency  of  the  institution.  It  is  most  illogical 
to  go  to  a  doctor,  because  you  like  him ;  or  to  a  surgeon,  because  you 
trust  him.    When  the  End  Result  System  is  well  seated  in  the  saddle, 

138 


you  can  select  a  surgeon  because  he  has  demonstrated  his  ability  to 
relieve  cases  similar  to  yours ;  and  it  is  for  his  interest  to  relieve 
you,  and  not  to  attempt  to,  if  he  cannot  make  pjood.  I  want  people 
to  come  to  this  hospital  for  the  same  reason  that  one  goes  to  a 
certain  grocer, — because  he  delivers  standard  goods,  not  because  one 
likes  him. 

When  these  Reports  grow  to  cover  large  numbers  of  cases,  they 
will  attract  consultants  and  patients,  but  now  they  merely  show 
what  a  one-horse  institution  this  is  as  compared  with  the  Charitable 
Hospitals.  From  the  expediency  point  of  view,  I  have  been  ineffi- 
cient in  my  advertising,  (for  I  consider  that  truthful  advertising 
may  be  an  honest  act,  and  recommend  it  to  the  Charitable  Hospitals, 
which  have  nothing  to  lose  by  being  honest). 

5.  Last  year  the  deficit  was  caused  by  shutting  down  the  hos- 
pital for  two  months,  so  that  I  could  take  some  vacation,  write  the 
last  Report,  and  prepare  the  Report  of  the  Committee  on  Hospital 
Standardization  of  the  Clinical  Congress  of  Surgeons.  Much  of  this 
time  was  spent  on  thinking  out  the  method  of  classification  illus- 
trated in  the  chart  inclosed  in  this  Report.  There  has  also  been  . 
much  time  taken  in  correspondence  about  this  and  other  public 
matters.  After  the  new  organization  and  the  inclosed  declaration 
of  aggressive  war  on  Harvard  and  her  affiliated  Hospitals,  this 
energy  is  going  into  business  for  faithful  managing  of  the  affairs 
of  the  stockholders.  If  Truth  prevails,  we  shall  win  even  against 
Harvard,  which  is  no  worse  than  all  other  American  Universities. 
It  would,  perhaps,  be  a  good  thing  for  Harvard  and  her  affiliated 
Hospitals,  if  I  had  a  fine  army  of  efficient  colleagues  to  enforce  the 
End  Result  System. 

Having  thus  considered  the  reasons  for  our  lack  of  Financial 
Success,  we  can  make  the  following  good  resolutions  for  the  future, 
and  thus  increase  our  business : 

1.  To  publish  no  more  cartoons. 

2.  To  advertise  directly  to  the  laity. 

3.  To  continue  to  employ  the  same  superintendent. 

4.  To  issue  no  more  Reports,  unless  they  are  paid  for. 

5.  To  sliirk  committee  work  for  national  medical  associations. 
In  other  words:   To  ^Iind  Our  Own  Business. 

Thus  I  shall  merely  manage  the  End  Result  Idea  for  those  who 
believe  in  it  enough  to  want  a  Report  for  a  dollar,  or  to  loan  money 
at  interest  to  enlarge  the  hospital. 

This  hospital  would  be  a  failure,  if  I  accei3ted  gifts  and  endow- 
ments. It  must  be  self-supporting  to  succeed.  The  public  must 
want  honest  surgery  and  be  willing  to  invest  in  it.  Many  of  my 
friends  and  acquaintances  are  among  the  richest  people  in  this 
Community,  yet  to  borrow  $100,000  on  a  business  basis  would  be 
more  difficult  for  me  than  to  beg  the  amount  for  a  charity!  They 
would  continue  to  r/ive  money  to  prolong  the  reign  of  King  Humbug 
ratlier  than   invest  money  in  an   institution   whose  only   chance  of 

134 


success  rests  on  the  hope  that  some  of  the  public  are  weary  of  his 
reign. 

In  the  Event  of  Financial  Success 

Last  year  I  did  at  this  hospital  74  operations,  at  an  average 
of  $61.12  apiece.  Suppose  I  should  become  a  popular  Back  Bay 
surgeon  and  should  get  $500  apiece  for  74  operations  next  year 
(a  few  of  my  patients  actually  do  value  my  services  at  this  amount). 
My  professional  income  would  be  $37,000. 

How  would  this  help  me? 

I  could  not  give  a  more  perfect  illustration  of  the  End  Result 
System  than  I  have  already  given  in  this  Report ! 

But  I  could  make  the  End  Result  System  fashionable ! 

The  Charitable  Hospitals  would  adopt  it ! 

Harvard  would  have  to  O.  K.  it. 

Colleagues  and  assistants  would  flock  to  my  Standard ! 

A  Surgeon's  Reward 

The  great  surgeons  of  the  world  have  certainly  seemed  to  receive 
compensation,  if  we  may  judge  by  the  ordinary  standards  of  wealth, 
honor,  and  power. 

They  have  been  chosen  as  presidents  and  executive  oflScers  of 
medical  and  surgical  societies ;  they  see  their  names  mentioned 
in  countless  special  articles  and  text-books ;  their  original  contribu- 
tions are  credited  for  generations  to  come;  they  are  honored  by  lay 
positions  of  trust  and  by  academic  degrees ;  they  are  the  center  of 
all  eyes  in  their  operating  theaters ;  and  they  accumulate  more  wealth 
than  they  have  time  to  enjoy.  But  these  are  not  the  real  rewards 
which  compensate  for  their  untiring  effort,  and  for  the  many  worries 
and  the  petty  frictions  which  mar  their  days.  Why  does  a  surgeon 
dread  retiring  from  practice.''  Why  do  the  older  men  cling  to  their 
hospital  positions  so  tenaciously? 

The  surgeon  s  reward  is  the  daily  pleasure  of  seeing  the  proof 
of  his  knowledge  and  skill  as  revealed  in  his  convalescent  patients. 

Imagine  the  pleasure  which  a  busy  surgeon  has  daily  in  the 
convalescent  smiles  of  ten  to  twenty  happy  patients,  each  of  whom 
feels  he  is  indebted  to  that  surgeon  for  his  recent  escape  from  the 
jaws  of  death.  The  flowers,  the  blue  ribbons,  the  pink  dressing 
wrappers,  and  the  first  shave  add  to  this  pleasant  experience  in 
proportion  as  the  patients  are  attractive,  interesting,  rich,  or  promi- 
nent. Then  add  a  hospital  visit,  with  a  trail  of  admiring  students, 
nurses,  and  visiting  doctors,  and  fifty  or  sixty  more  or  less  grateful 
patients. 

The  wonder  is  that  any  surgeons  have  time  or  inclination  to 
consider  the  joyless  part  of  their  lives,  made  up  of  professional 
honors,  medical  societies,  sitting  on  platforms,  keeping  up  the 
standards  of  their  hospitals,  wearily  writing  papers  and  text-books, 
or  making  original  observations  which  will  destroy  their  conservative 

136 


reputation  in  this  generation,  and  only  be  recognized  by  the  next. 
Yet  our  Hospital  Trustees  the  Country  over  continue  to  put  a 
premium  on  neglecting  these  joyless  but  essential  things.  It  is  only 
the  giants  like  Crile,  Gushing^  Brewer^  and  Edward  ]Martin  who 
can  do  all  these  weary  things  and  still  have  energy  enough  left  to 
beat  their  "practical"  competitors  at  their  own  games. 

When  will  Trustees  realize  that  hospital  opportunity  is  essential 
to  the  surgeon,  and  make  him  pay  for  it  with  some  effort  for  the 
general  good.^  Do  they  deny  that  study,  care,  thoroughness,  and 
scientific  analysis  have  more  to  do  with  the  efficiency  of  a  surgeon 
than  his  popularity  and  dexterity  ?  Surely  it  is  time  to  bury  the  old 
ideas  of  "nerve,"  "steady  hand,"  and  "graceful"  operating,  and 
to  teach  the  public  that  knowledge  of  surgical  science  and  steadfast 
care  and  judgment  in  applying  it  make  the  surgeon  of  today. 

Eccentricity 

Persons  are  called  eccentric,  when  their  expressed  view  or 
behavior  is  distinctly  different  from  the  average,  whether  in  hospital 
management  or  other  affairs  in  life.  Eccentricity  is  almost  a  term 
of  reproach,  but  it  is  not  quite  so,  for  to  be  different  from  the 
average,  one  need  not  necessarily  be  below  it.  The  eccentric  whose 
eccentricity  is  eventually  proved  correct  may  in  time  become  a 
conservative.  Eccentrics  are  generally  obliged  to  publish  their 
own  literature  (as  I  do  these  Reports).  It  would  be  useless  to 
offer  them  to  the  Boston  Medical  and  Surgical  Journal.  The 
Editors  do  not  care  to  contradict  anything  I  have  said  in  these 
publications,  nor  have  they  questioned  the  accuracy  of  any  state- 
ment. They  know  that  my  contentions  are  correct,  but  they  would 
not  print  them,  because  they  fear  the  disapproval  of  those  conserva- 
tive and  vested  interests  which  control  the  Harvard  Medical  School 
and  its  affiliated  Hospitals. 

It  is  true  that  I  am  an  eccentric  from  the  Massachusetts 
General  Hospital, — that  I  flew  away  from  the  center.  So  did 
Thayer,  Finney,  and  Gushing  to  Baltimore;  Moffatt  and  Lucas  to 
San  Francisco;  Robinson  and  Hedbloom  to  Rochester;  Murphy 
to  St.  Louis ;  Kidner  to  Detroit ;  Whiteside  to  Portland ;  John  Little 
to  Labrador,  and  a  host  of  others  to  other  places.  I  am,  perhaps, 
less  eccentric,  since  I  have  remained  in  sight  of  the  Massachusetts 
General  Hospital.  What  a  hospital  might  have  been  made  with 
these  men,  if  we  had  kept  them !  How  it  might  have  turned  the  tide 
of  sacred  pilgrimage  from  Rochester,  Minnesota,  if  we  had  monop- 
olized Clinical  Truth,  instead  of  letting  the  Mayos  do  it!  There 
were,  of  course,  many  reasons  why  these  men  left,  but  one,  I  venture, 
weighed  heavily  with  every  one  of  them, —  they  had  no  desire  to 
stay  in  a  seniority  line  for  the  ultimate  privilege  of  keeping  the 
young  men  down  as  they  were  kept  down  by  their  seniors. 

However,  the  eccentric  quality  of  a  Seniority  System  is  perhaps 
its  best  argument.     It  may  be  a  good  system  that  drives  away  the 

180 


ambitious  young  men^  and  keeps  the  ones  who  are  tame  enough  to 
let  those  in  front  pull  them  up,  and  those  behind  boost  them  up, 
but  I  do  not  believe  it  is. 

So  I  am  called  eccentric  for  saying  in  public: 
That  Hospitals,  if  they  wish  to  be  sure  of  improvement, 

1.  Must  find  out  what  their  results  are. 

2.  Must  analyze  their  results,  to   find  their  strong  and  weak 

points. 

3.  Must  compare  their  results  with  those  of  other  hospitals. 

4.  Must  care  for  what  cases  they  can  care  for  well,  and  avoid 

attempting  to  care  for  cases  which  they  are  not  qualified 
to  care  for  well. 
6.    Must  not  pretend  that  work  which  they  do  as  a  competitive 
business  is  Charity. 

6.  Must  assign  the  cases  to  members  of  the  Staff   (for  treat- 

ment)   for  better  reasons  than  seniority,  the  calendar, 
or  temporary  convenience. 

7.  Must  teach  medical  students  ethics  by  example  instead  of 

by  precept. 

8.  Must  welcome  publicity  not  only  for  their  successes,  but  for 

their  errors,  so  that  the  Public  may  give  them  their  help 
when  it  is  needed. 

9.  Must  promote  members  of  the  Staff  on  a  basis  which  gives 

due  consideration  to  what  they  can  and  do  accomplish 
for  their  patients. 
Such  opinions  will  not  be  eccentric  a  few  years  hence. 

Offers  to  Charitable  Hospitals 

In  retiring  to  a  private  hospital,  I  am  not  unwilling  to  do  chari- 
table work.  I  will  accept  any  position  on  the  Surgical  Staff  of  the 
Massachusetts  General  or  Boston  City  Hospitals,  provided  that 
the  End  Results  of  the  cases  which  are  submitted  to  my  care  are 
considered  in  comparison  with  those  of  my  colleagues  whenever 
there  is  a  question  of  promotion. 

If  the  Massachusetts  General  Hospital  will  reappoint  me  to  my 
former  position,  I  will  provide  the  salary  for  an  End  Result  Clerk 
to  make  out  End  Result  Cards  for  all  the  cases  which  have  been 
treated  at  the  Hospital  since  the  beginning  of  this  century. 

I  will  do  100  operations  a  year  at  any  Charitable  Hospital — 
for  nothing.  Or,  I  will  do  300  a  year  for  $25  an  operation,  and  no 
operating  outside  the  Hospital.  Or,  I  will  do  200  or  less  for  $10 
an  operation,  provided  I  may  do  private  practice  as  well. 

If  any  of  our  Charitable  Hospitals,  by  an  analysis  of  the  End 
Results  of  their  cases,  find  that  the  Results  of  any  particular  class 
of  surgical  cases  are  unsatisfactory,  I  will  undertake  to  take  charge 
of  such  cases  and  make  them  more  satisfactory. 

If  the  Trustees  of  any  of  our  Charitable  Hospitals  empower  me 
to  do  so,  I  will  organize  an  End  Result  System  suitable  to  their 

137 


needs,  which  will  permit  them  to  keep  a  definite  record  of  the  thera- 
peutic efficiency  of  their  whole  organization,  and  of  the  individual 
members  of  their  Staffs.  But,  in  order  to  do  this,  I  must  be  em- 
powered to  insist  that  all  doubtful  cases  must  be  referred  to  me  for 
operation,  or  for  assignment  to  that  member  of  the  Staff  who  in  my 
opinion  is  best  qualified  to  care  for  each  particular  case. 

An  analysis  of  my  results  at  the  ]Massachusetts  General  Hospital 
and  at  this  hospital  shows: 

(1)  That  I  had  no  deaths  in  cases  of  hysterectomy  for  fibroids 

of  the  uterus. 

(2)  That  in  surgery  of  the  gall  bladder  I  have  had  10  deaths. 

I  should,  therefore,  like  to  offer  my  services  to  any  hospital 

(1)  Either  to  do  hysterectomies  for  fibroids,  which  I  can  prove 

I  do  satisfactorily,  or 

(2)  To  do  gallstone  surgery,  which  I  am  interested  to  study  for 

the  sake  of  my  own  improvement,  and  because  there  is 
much  for  all  surgeons  to  learn  in  this  branch  of  work. 

If  any  Charitable  Hospital  has  a  high  mortality  in  its  night 
emergency  work,  I  should  be  happy  to  take  charge  of  it,  and  will 
guarantee  to  improve  the  percentage  of  mortality  during  the  next 
year,  and  the  general  character  of  the  results  in  those  who  survive. 

But  I  ask  for  these  positions.  Emerson  says:  "The  highest  price 
one  can  pay  for  a  thing  is  to  ask  for  it." 

Altogether,  I  am  unwilling  to  serve  any  Hospital  under  a  Senior- 
ity System,  because  such  a  system  assumes  that  I  have  something 
to  give  to  the  Hospital,  not  something  to  get  out  of  the  Hospital. 
"A  fair  exchange  is  no  robbery."  It  saves  the  Trustees  trouble  to 
have  a  Seniority  System.  It  is  a  wholesale  bargain,  and  saves  effort, 
—  and  therefore  cannot  be  the  best.  Why  not  make  some  individual 
bargains .''  I  have  made  some  tentative  offers,  and  I  will  accept  that 
position  which  seems  the  most  to  my  interest,  and  the  one  for  which 
I  can  best  arrange.  Trustees  save  themselves  much  trouble  by  let- 
ting the  doctors  seek  the  Hospital,  rather  than  having  the  Hospital 
seek  the  doctors.  The  one  allows  the  doctors  to  take  their  pay  out 
in  experimenting  on  the  patient;  the  other  means  that  the  Trustees 
would  pay  the  doctor  for  taking  their  responsibility. 

Now  no  Trustees  will  accept  these  offers.  They  neither  wish 
to  make  sure  that  all  their  patients  are  relieved  nor  that  they  are 
all  studied.  They  wish  to  go  on  in  the  same  old  way,  and  not  be 
bothered.  "Let  the  Staff  run  a  monopoly,  if  they  are  smart  enough 
to  do  it;  to  succeed,  tliey  will  have  to  take  care  of  the  patients." 
Thus  thinks  the  hard-headed  business  man. 

Nothing  illustrates  the  vanity  of  this  Pretense  that  Surgeons 
operate  at  Hospitals  for  Charity  better  than  the  fact  that  I  am  not 
only  ready,  but  glad  to  operate  for  nothing  on  any  Charitable  Case 
at  any  Charitable  Hospital.  Ask  your  Staff  to  let  me  operate  for 
a  month,  and  see  lunv  indignant  they  will  be.    Ask  them  to  give  me  a 

138 


chance  to  examine  and  select  to  operate  on  (if  I  think  the  chances 
good  and  the  patients  are  willing)  all  cases  in  which  they  advise 
against  operation ! 

The   Proof   That  the  Writer  Deserves  an  Appointment 
AT  A  Charitable  Hospital 

The  following  is  an  attempt  to  show  that  it  is  possible  to  rate 
a  surgeon  by  the  results  which  he  obtains  in  those  cases  that  are 
intrusted  to  his  care.  For  fifteen  years  the  writer  served  as  assist- 
ant visiting  surgeon  to  the  Massachusetts  General  Hospital.  During 
this  period  a  great  variety  of  surgical  cases  were  intrusted  to  him 
for  operation.  At  this  time  eighteen  surgeons  were  on  duty,  and  each 
operated  on  approximately  the  same  number  and  variety  of  cases, 
and  little  attempt  was  made  to  select  the  best  surgeons  for  the  most 
difficult  cases.  In  fact,  the  reverse  was  the  case,  for  in  general  the 
emergency  cases  which  came  in  at  night  or  during  the  afternoon 
hours,  were  operated  on  by  the  younger  and  less  experienced  men, 
who  gladly  availed  themselves  of  the  opportunity,  while  their  busier 
seniors  were  attending  to  their  private  practice  or  resting. 

These  emergency  cases,  as  a  rule,  were  the  most  difficult  possible 
cases  to  operate  upon.  They  were  usually  "last  resort"  operations, 
requiring  the  keenest  surgical  judgment  and  intuitive  ability  (which 
only  experience  can  cultivate)  to  make  "snap  diagnoses."  If  any 
kind  of  cases  demands  speed  and  manual  skill  in  operating,  these 
traumatic  and  septic  emergencies  certainly  do.  A  hospital  which 
was  organized  to  obtain  the  best  results,  could  not  possibly  allot  such 
cases  to  its  less  experienced  surgeons.  However,  the  writer,  like 
all  other  ambitious  surgeons,  was  glad  of  the  opportunity,  and 
availed  himself  of  it  to  the  best  of  his  ability.  Even  now,  at  forty- 
seven,  he  would  be  glad  to  have  the  same  chance. 

If  the  records  of  the  hospital  during  these  fifteen  years  are 
examined,  they  will  show  that  the  cases  on  which  I  operated  were 
1,741  in  number,-"^  and  that  they  represented  as  large  a  proportion 
of  difficult  cases  as  those  of  the  other  surgeons. 

Would  it  be  possible  to  compare  the  records  of  each  of  these 
surgeons  with  mine,  and  to  determine  by  the  End  Results  which 
was  the  best  surgeon?  Of  course,  in  each  surgeon's  practice  this 
hospital  work  formed  only  a  proportion,  and  it  would  be  quite  pos- 
sible to  argue  that  even  if  my  results  in  the  Hospital  proved  to  be 
better  than  those  of  some  other  surgeon,  he  might  have  done  much 
better  work  outside  of  the  Hospital.  My  contention  is,  that  even 
if  this  were  the  case,  it  would  make  no  difference  as  far  as  the 
efficiency  of  the  hospital  work  was  concerned;  that  no  matter  how 
popular,  how  painstaking,  how  skillful  the  surgeon  might  be  in  his 
private  practice,  these  virtues  would  not  condone  for  good-natured 
slackness   in  discipline,  carelessness,   surgical   gymnastics  and  dis- 

1  Many  of  these  had  several  operations  at  the  same  time,  and  many  others  were  oper- 
ated on  two  or  more  times. 

139 


play,  hurry,  and  neglect  of  disagreeable  essentials  in  his  hospital 
work. 

To  make  the  whole  hospital  efficient,  it  is  necessary  to  have  a 
Staff  who  not  only  can  be,  but  are  efficient. 

As  it  is  impossible  for  me  to  present  the  entire  End  Result 
Record  of  all  the  cases  operated  on  by  the  eighteen  surgeons  for 
fifteen  years,  I  can  only  base  my  argument  on  the  consideration  of 
my  own  record.  Unfortunately,  as  explained  previously,  I  cannot 
even  present  the  End  Result  Record  of  my  own  successful  cases. 
However,  there  can  be  no  objection  to  my  publishing  the  results 
of  those  of  my  cases  which  did  not  survive,  and  so  I  base  my  argu- 
ment on  the  corollaries  taken  from  abstracts  of  these  cases.  By  a 
consideration  of  all  those  cases  which  died  after  my  operations, 
I  propose  to  show  that  my  standards  of  surgical  skill,  surgical 
judgment,  surgical  care,  and  of  those  qualities  which  contribute  to 
successful  results  in  surgical  cases,  were  of  the  highest  order. 

I  claim  that  I  had  a  minimum  number  of  preventable  fatalities, 
and  I  challenge  any  one  to  show  that  any  other  surgeon  who  oper- 
ated at  the  hospital  during  these  fifteen  years  had  as  few  in  pro- 
portion to  the  number  of  difficult  cases  which  were  successful. 

I  claim  that  in  almost  all  of  the  cases  in  the  following  list,  the 
cause  of  death  was  the  patient's  condition  or  disease,  and  not  my 
errors  of  diagnosis,  skill,  judgment,  or  care.  107  of  the  141  were 
grave  emergencies. 

I  claim  that  by  a  consideration  of  the  records  of  these  cases, 
a  committee  of  surgeons  (who  had  no  personal  interest  in  the  matter) 
could  tell  that  I  had  no  deaths,  during  fifteen  years'  service,  that 
were  criticizable  because  of  carelessness,  neglect,  lack  of  skill  or 
judgment,  or  other  obviously  preventable  cause.  No  cases  where 
death  was  due  to  hemorrhage,  sepsis,  shock,  ansesthesia  accidents, 
lack  of  manual  dexterity,  anatomical  knowledge,  surgical  instinct, 
pre-operative  care,  or  even  diagnosis  or  other  preventable  error,  will 
be  found  in  this  list,  unless  the  patient  was  in  a  very  serious  con- 
dition before  the  operation. 

Now  if  I  served  all  these  years,  and  did  approximately  2,000 
(many  cases  were  operated  on  more  than  once)  more  or  less  serious 
operations  without  losing  cases  in  which  the  pre-operative  condition 
was  not  serious,  it  proves  that  I  was  a  careful,  painstaking,  compe- 
tent operator.  If  any  blame  can  be  placed  for  these  deaths  at  all, 
it  must  fall  on  the  organization  which  permitted  the  assignment  of 
such  grave  cases  to  so  inexperienced  a  man,  appointed  through 
nepotism ! 

It  seems  to  me  that  I  could  hardly  offer  better  evidence  than  this 
of  my  right  to  an  appointment  at  a  Charitable  Hospital.  Possibly 
the  presentation  of  the  abstract  of  all  those  cases  which  survived 
might  be  considered  more  reliable  evidence,  but  to  my  mind  this 
negative  evidence  is  superior  as  demonstrating  true  surgical  ability. 
If  the  positive  evidence  is  desired, the  Trustees  of  the  hospital  should 

140 


have  it  in  their  records !    They  should  be  able  to  tell  to  what  extent 
those  cases  which  survived  after  my  operations  were  benefited ! 

How  is  any  member  of  the  Staff  to  realize  that  for  the  good  of 
the  hospital  he  should  resign?  He  can  only  be  sure  of  one,  to  him 
important,  thing — that  if  he  does  resign,  it  will  mean  loss  of  pres- 
tige, loss  of  practice,  and  the  end  of  his  career  as  a  surgeon.  I  have 
been  through  part  of  this  experience  during  the  last  two  years,  but 
by  assuming  the  financial  burden  of  this  hospital,  I  have  been  able 
to  cling  to  my  ambition  to  be  a  good  surgeon.  My  opportunity  to  be 
a  great  surgeon  has  gone,  unless  some  large  hospital  will  give  me 
opportunity  for  manual  practice. 


If  I  can  make  such  an  analysis  of  my  cases,  why  could  they  not 
do  it  at  a  Charitable  Hospital  when  there  is  question  of  promotion? 


In  connection  with  reforms  in  most  large  hospitals,  one  often 
hears  "They"  spoken  of.  "They"  usually  leave  things  undone. 
It  took  a  long  time  for  me  to  realize  that  "They"  meant  "We"  or 
"I,"  or  any  one  that  was  interested  enough  to  do  the  things  for 
their  own  sake,  without  reward. 

The  existence  of  this  illusive  "They"  in  a  hospital  is  a  sure  sign 
of  the  need  of  an  Efficiency  Committee.  "They"  should  suggest  the 
resignation  of  the  incompetent ! 


141 


102  Emergencies 


-12 


DIAGNOSES  OF  THE   141  CASES  WHICH  DIED   AFTER  OPERA- 
TION   BY   E.   A.    C.    AT   THE    MASSACHUSETTS    GENERAL 
HOSPITAL  DURING  THE  YEARS  1900  TO  1914  INCLUSIVE 

^Suppurative  Appendicitis 23 

Intestinal  Obstruction  from  Cancer    .     .  5 

Intestinal  Obstruction  from  Other  Causes 

From  Adhesions  and  bands     ....       3 

"       Mesenteric  thrombosis   .... 

"       Tuberculous  stricture     .... 

"        Meckel's  diverticulum   .... 

"       Volvulus  cecum 

"       Undetermined 

Septic  Conditions 

Abscess  of  cheek 

Pelvic  abscess   (fecal  fistula)        .     .     . 
Pelvic  abscess  (vaginal  drainage)     .     . 

Unknown  peritonitis 

Abscess  of  neck  (enteritis)       .... 

Acute  pericarditis 

Abscess  of  neck   (D.  T.'s) 

Acute  pancreatitis 

Acute  endocarditis 

Pneumococcus  peritonitis 

Acute  pancreatitis  (mania)      .... 
Abscess  of  liver  (?) 

Other  Conditions 

Skull  fractures 8 

Crushed  or  septic  legs — -Amputations  .       7 

Multiple  injuries 3 

Traumatic  tetanus 4 

Fractured  spine 2 

Ruptured  or  perforated  viscera  ...     19 

Strangulated  hernia 8 

Tuberculous  peritonitis 1 

Transfusion  for  ruptured  liver    .     •     .       1 — 53 
''  Operations  for  Cancer  of  Stomach  ...  7 

Other  Operations  for  Cancer 

Uterus 2 

Breast 1 

Lower  jaws 1 

Sarcoma  intestine 1 

Lip  and  neck 1 

Upper  jaws 1 

Duodenal  papiUa 1 8 

Complicated  or  acute  gallstone  cases  .     .  6 

Operations  for  Various  Other  Conditions 

Chronic  appendicitis  (?) 1 

Cleft  palate 1 

Ventral  hernia 1 

Contracture  from  burns       1 

Cirrhosis  of  liver 1 

Huge  renal  calculi 1 

Multiple  pelvic  operations 1 


39  Other  Operations 
(including  3  emergencies 
for  cancer  of  stomach 
and  2  emergency 
gallstone  cases) 


Stricture  urethra  (perineal  section) 

Gasserian   ganglion 

Hydrocele  and  Hernia  (Pneumonia  on 

45th  day)      

Gastric  ;irid  duodenal  ulcer  (chronic  per- 
foration)   


1—11 


141 


All  patients  whom  I  operated  on^  and  who  died  in  the  Hospital, 
are  included^  even  if  operated  on  also  by  other  surgeons,  or  by  house 
surgeons  under  my  direction.  Let  the  reader  compare  these  abstracts 
with  the  abstracts  of  deaths  in  the  last  three  Massachusetts  General 
Hospital  Reports. 

SUPPURATIVE  APPENDICITIS 

1.  Apr.  29,  1900.  E.  S.  370-98.  Male — 22.  Abdom.  pain  and  vomiting  for 
7  days.  General  peritonitis.  Op.  E.  A.  C. — Median  incision.  Washed 
with  salt  sol.    Died  same  day. 

2.  July  23,  1900.  E.  S.  374-140.  Male — 14.  Abdom.  pain  4  days.  General 
peritonitis.  Op.  E.  A.  C— Pus  and  fibrin  in  peritoneal  cavity.  Appen- 
dix gangrenous.    Death  on  2d  day. 

3.  July  2.5,  1900.  E.  S.  374-146.  Male— 27.  Sick  2  weeks.  Violent  abdom. 
pain  24  hrs.  General  peritonitis.  Op.  E.  A.  C. — Bowels  injected; 
covered  with  iibrin  and  j^us.    Appendix  gangrenous.    Died  in  24  hrs. 

4.  Aug.  15,  1900.  E.  S.  372-204.  Female— 15.  Abdom.  pain  5  days,  and 
vomiting  2  days.  General  peritonitis.  Op.  E.  A.  C. — Seropurulent  fluid. 
Appendix  gangrenous.    Death  on  6th  day. 

5.  July  2,  1901.  E.  S.  388-238.  Female— 13.  Abdom.  pain,  etc.,  4  days. 
General  peritonitis.  Op.  E.  A.  C. — Median  incision,  free  pus.  Appendix 
gangrenous.    Died  in  24  hrs. 

6.  Aug.  24,  1901.  E.  S.  394-133.  Male— 19.  Abdom.  pain,  etc.,  over  48 
hrs.  General  peritonitis.  Op.  E.  A.  C. — Free  turbid  fluid.  Ulcerated 
appendix.    Death  in  5  days. 

7.  Aug.  30,  1901.  E.  S.  394-160.  Male— 17.  Abdom.  pain,  etc.,  for  6  days. 
General  peritonitis.  Op.  E.  A.  C. — Appendix  gangrenous;  near  liver. 
Death  on  7th  day,  probably  from  perforation  of  subdiaphragmatic 
abscess  into  lung. 

8.  Aug.  30,  1901.  E.  S.  394-158.  Male— 7.  Had  been  operated  on  by 
another  surgeon  on  11th  day  of  attack,  Oct.  19,  1899.  Abscess  was 
drained  without  finding  appendix.  Re-entered  Aug.  30,  1901,  on  5th  day 
of  another  attack.  Op.  E.  A.  C. — Large  slough  in  place  of  appendix. 
Death  on  6th  day. 

9.  Sept.  6,  1901.  E.  S.  392-136.  Female— .5.  Abdom.  pain,  etc.,  4  days. 
General  peritonitis.  "Child  lying  in  stupor."  Op.  E.  A.  C. — Free  pus 
everywhere.  Appendix  too  buried  to  attempt  removal.  Enterostomy. 
Died  in  2  hrs. 

10.  Sept.  19,  1901.  E.  S.  394-234.  Male— 37.  Abdom.  pain,  etc.,  4  days. 
General  peritonitis.  Op.  E.  A.  C. — Enterostomy  without  attempting  to 
remove  appendix.    Drainage.    Died  on  2d  day. 

11.  Mar.  12,  1902.  S.  S.  126401.  Male— 10.  Abdom.  pain,  etc.,  6  days. 
General  peritonitis.  Op.  E.  A.  C. — Fecal  contents  washed  from  stomach. 
Abdom.  full  of  pus.  Gangrenous  appendix.  Enterostomy.  Died  same 
day. 

12.  Aug.  9,  1902.  E.  S.  128468.  Female— 8.  Abdom.  pain,  etc.,  over  48  hrs. 
Localized  appendix  abscess  in  pelvis.  Op.  E.  A.  C. — Appendectomy  and 
drainage.  On  10th  day  operated  on  again  for  post-operative  obstruc- 
tion in  ileum.    Died  on  following  day. 

18.  Aug.  9,  1902.  E.  S.  410-185.  Female— 42.  Abdom.  pain,  etc.,  7  days. 
General  peritonitis.  Op.  E.  A.  C. — Enterostomy  and  drainage  under 
local  anaesthesia.    Death  in  24  hrs. 

143 


14.  Dec.  26,  1902.  W.  S.  130361.  Male— 21.  Abdom.  pain,  etc.,  4  days. 
General  peritonitis.  Op.  E.  A.  C. — Free  pus;  fibrin  on  bowels;  gan- 
grenous appendix.    Enterostomy.    Died  on  2d  day. 

16.  July  17,  1903.  E.  S.  133202.  Male— 9.  Abdom.  pain,  etc.,  3  days.  Op. 
E.  A.  C. — General  peritonitis;  gangrenous  appendix.  Two  later  ops. 
for  drainage  of  secondary  abscesses — pelvic  and  subdiaphragmatic. 
Death  after  the  latter  on  20th  day. 

16.  Mar.  25,  1904.  E.  S.  136662.  Male-^8.  Abdom.  pain,  etc.,  4  days.  Op. 
E.  A.  C. — General  peritonitis;  gangrenous  appendix.  Died  on  8th  day. 
Subphrenic  abscess? 

17.  Aug.  1,  1904.  E.  S.  138518.  Male— 18.  Abdom.  pain,  etc.,  5  days. 
General  peritonitis.  Op.  E.  A.  C. — Intestines  red  and  coated  with 
fibrin,  etc.    Died  on  same  day. 

18.  Dec.  28,  1905.  E.  S.  145774.  Male— 54.  Abdom.  pain,  etc.,  5  days. 
General  peritonitis.    Op.  E.  A.  C. — Free  pus,  etc.    Died  on  4th  day. 

19.  Oct.  28,  1907.  E.  S.  155466.  Female— 9.  Abdom.  pain,  etc.,  24  hrs. 
Op.  E.  A.  C. — Free  pus  in  abdomen.  Perforated  appendix  removed; 
drainage.  Two  days  later  op.  by  F.  B.  Harrington — Further  drainage. 
Death  on  same  day. 

20.  Jan.  17,  1908.  E.  S.  156660.  Male— 26.  Abdom.  pain,  etc.,  for  7  days, 
but  severe  for  only  a  few  hrs.  Op.  E.  A.  C. — Turbid  abdom.  fluid. 
(Streptococci.)  Appendectomy.  Large  wound  for  general  exploration. 
Protrusion  of  bowel  on  2d  day.    Wound  broke  down.    Death  on  6th  day. 

21.  Oct.  14,  1908.  E.  S.  160677.  Male — 77.  Abdom.  pain,  etc.,  for  4  days. 
Op.  E.  A.  C. — Appendix  abscess  containing  10  ounces.  A  perforation 
located  in  posterior  wall  of  cecum,  probably  in  adherent  appendix. 
Drainage  without  search  for  appendix.  Died  in  24  hrs.  Autopsy 
showed  appendix  had  sloughed  away. 

22.  Mar.  1,  1909.  S.  S.  162684.  Male — 45.  Abdom.  pain,  etc.,  7  daj^s.  Some 
jaundice.  Op.  E.  A.  C. — High  appendix  in  wadded  omentum  removed. 
Thickening  and  induration  about  portal  vein  noted.  Pylephlebitis? 
Died  next  day. 

23.  Dec.  18,  1912.  E.  S.  186626.  Male— 17.  Abdom.  pain,  etc.,  5  days. 
Large  indurated  abscess.  Op.  E.  A.  C. — 1st  incision  in  rt.  loin.  During 
manipulation  abscess  suddenly  collapsed — evidently  discharging  into 
bowel.  Abscess  cavity,  when  opened,  contained  but  little  pus  and  a 
gangrenous  appendix.  A  second  anterior  incision  was  made  and  through 
and  through  drainage  established.  A  fecal  fistula  resulted.  Death  on 
12th  day  from  pneumonia  which  began  on  10th  day.  Perhaps  sub- 
phrenic abscess. 

Note  on  Suppurative  Appendicitis 

It  will  be  observed  that  fourteen  of  these  twenty-three  cases  were  lost 
before  1903,  or  during  the  first  three  years  of  my  service,  and  that  during 
1909-1914  I  lost  only  one  case. 

This  is  a  reflection  on  organization,  not  a  compliment  to  my  ability.  Dur- 
ing the  i)eriod  from  1900-1908,  Murphy  and  Ochsner  were  having  their 
famous  battle  in  regard  to  the  proper  treatment  of  general  peritonitis,  and 
I  was  keenly  interested,  and  never  failed  to  take  the  chance  to  operate  for 
this  condition.  I  often  operated  on  cases  which  had  been  passed  by  my 
seniors.  Examination  of  the  hospital  records  will  show  that  during  this 
period  many  other  cases,  almost  as  severe  in  type  as  these,  recovered  after 
my  operations.  I  was  among  the  first  to  use  the  principles  advocated  by 
Ochsner,  and  among  the  first  to  find  that  perforation  of  a  duodenal  ulcer 
must  always  be  considered  in  cases  of  general  peritonitis. 

The  treatment  of  these  cases  has  improved  greatly  since  those  days.  The 
use  of  rubber  gloves,  wet  gauze,  and   cigarette  wicks  has  diminished  the 

144 


chance  of  post-operative  obstruction,  and  we  now  know  how  dangerous 
pre-operative  and  post-operative  catharsis  is.  A  few  of  these  cases  I  could 
probably  save  now,  if  I  could  do  them  over  again,  but  the  difiFerence  would 
be  due  to  the  general  advance  of  surgery  rather  than  to  my  own  increased 
skill. 

For  instance,  in  Case  25,  after  end-to-end  anastomosis  of  the  sigmoid, 
a  cathartic  and  an  enema  were  given  on  the  second  day!  Now,  I  should  not 
attempt  to  move  the  bowels  for  a  week.  In  those  days  it  was  customary  to 
give  calomel  on  the  second  day.  It  is  my  belief  that  many  cases  died  from 
this  cause. 

INTESTINAL  OBSTRUCTION  FROM  CANCER 

24.  July  15,  1901.  E.  S.  390-194.  Male— 32.  Chronic  obstruction  with  in- 
crease of  symptoms.  Op.  E.  A.  C. — Free,  dark  red  fluid.  Large  tumor 
of  bowel  resected;  intestine  torn  in  so  doing.  (Sarcoma.)  Enteros- 
tomy.   Died  next  day. 

25.  July  22,  1901.  E.  S.  390-230.  Male— 50.  Obstruction  for  5  days.  Op. 
E.  A.  C. — Excision  of  cancerous  stricture  of  sigmoid.  End-to-end 
anastomosis.    Death  on  4th  day — leakage. 

26.  Nov.  18,  1905.  E.  S.  528-26.  Male— 54.  Chronic  obstruction  with  acute 
sjTnptoms.  Op.  E.  A.  C. — Cecostomy  for  cancer  of  hepatic  flexure. 
Lived  12  days.  Autopsy:  Septicemia.  Inoperable  cancer  with  metas- 
tases. 

27.  Aug.  22,  1906.  E.  S.  149101.  Male— 35.  A  cachectic  case  previously 
operated  on  by  two  other  surgeons  by  drainage  of  an  ischio-rectal 
abscess  and  cecostomy.  Op.  E.  A.  C. — More  complete  drainage  of  ab- 
scess. Died  5  weeks  later.  Autopsy  showed  high  cancer  of  rectum, 
pneumonia,  and  septicemia. 

28.  Oct.  2,  1909.  E.  S.  166158.  Male— 38.  Hematuria  and  obstruction  of 
bowels  for  2  days.  Distention.  Op.  E.  A.  C. — Drainage  of  ascitic  fluid. 
Extensive  malignant  disease  of  unknown  origin.  Nothing  done.  Died 
on  10th  day.  Wound  clean.  Autopsy:  Cancer  of  stomach  with  metas- 
tases.   Papilloma  of  bladder,  etc. 

INTESTINAL  OBSTRUCTION  FROM  OTHER  CAUSES 

29.  July  31,  1900.  E.  S.  374-176.  Male— 78.  Obstruction  4  days.  Op.  E. 
A.  C. — A  constricting  band  obstructing  small  intestine  found  and  cut. 
Intestinal  contents  evacuated  with  trochar.    Died  same  day. 

30.  June  26,  1901.  E.  S.  390-124.  Male— 68.  Sick  3  weeks."  Obstruction 
3  days.  Op.  E.  A.  C. — Mesenteric  thrombosis;  resection  6  feet  of  intes- 
tine.   No  anastomosis.    Died  next  day. 

31.  July  17,  1901.  E.  S.  392-36.  Female— 33.  Chronic  obstruction  2  yrs. 
Recently  worse.  Op.  E.  A.  C— Portion  of  small  intestine,  including 
several  tuberculous  strictures,  removed.  End-to-end  suture.  Death  on 
12th  day  from  pneumonia. 

82.  Aug.  17,  1901.  E.  S.  394-102.  Male-47.  Partial  obstruction  5  days. 
Had  been  op.  by  E.  A.  C.  a  year  previously  for  appendicitis.  Hernia 
in  scar.  Op.  E.  A.  C. — Cecostomy.  Vomiting  and  hiccough  persisted 
for  a  week,  when  he  died  of  exhaustion. 

33.  July  3,  1902.  E.  S.  412-163.  Male— 30.  Sick  for  3  weeks.  Obstruction 
2  days.    Op.  E.  A.  C. — Removal  of  a  band  from  Meckel's  diverticulum 

which  had  obstructed  small  intestine.  Died  on  2d  day.  Delirium  tremens. 

34.  July  18,  1903.  E.  S.  133222.  Male— 19.  Previously  op.  bv  another 
surgeon  a  year  before  for  appendicitis.  Typical  svm"ptoms  of  obstruc- 
tion for  2  days.  Op.  E.  A.  C— Removal  of  a  constricting  band  from 
Meckel's  diverticulum.  Enterostomy  and  evacuation  of  intestinal  con- 
tents.   Died  on  2d  day. 

145 


35.  Dec.  .5,  1907.  E.  S.  161404.  Male— 62.  Obstruction  3  days.  Op.  E.  A. 
C. — Huge  volvulus  of  cecum;  reduced;  cecostomy.  Normal  convales- 
cence until  16th  daj'.    Sudden  death  from  pulmonary  embolism. 

36.  Feb.  18,  1907.  E.  S.  1.51.57.5.  Female — 49.  Chr.  abdom.  symptoms  for 
several  mos.  Acute  for  3  days.  Waited  24  hrs.  for  peritonitis  to  local- 
ize. Op.  E.  A.  C. — Fibrin  on  intestines,  etc.  Cause  of  obstruction  and 
peritonitis  not  determined.    Enterostomy.    Died  on  6th  day. 

37.  Apr.  11,  1910.  S.  S.  169347.  Male— 18.  Post-operative  intestinal  ob- 
struction several  days  after  appendectomy  (by  another  surgeon).  Gen- 
eral peritonitis.  Op.  E.  A.  C. — Enterostomy.  Died  14  days  later  of 
pneumonia. 

SEPTIC  CONDITIONS 

88.  June  26,  1901.  E.  S.  390-126.  Male— 21.  Septicemia  and  diffuse  ab- 
scess of  cheek.  Op.  E.  A.  C. — Incision  and  drainage.  Died  the  follow- 
ing day. 

39.  July  li,  1901.  E.  S.  392-26.  Female— 86.  Sick  2  weeks.  Op.  E.  A.  C. 
— Abdom.  incision  and  drainage  of  a  pelvic  abscess.  Fecal  fistula 
(probably  pre-operative).    Died  on  13th  day. 

40.  Apr.  6,  i902.  E.  S.  404-124.  Female — 23.  Large  pelvic  abscess.  Op. 
E.  A.  C. — Vaginal  drainage  of  abscess.  Later  three  more  attempts 
were  made  to  establish  satisfactory  drainage.  Two  by  E.  A.  C.  and 
the  last  by  F.  B.  Harrington.    Death  in  3  mos. 

41.  Aug.  27,  1902.  E.  S.  128713.  Male— 37.  A  moribund  case  of  peri- 
tonitis of  unknown  origin.  Op.  E.  A.  C. — Cocaine.  Drainage  of  peri- 
toneum.   Died  same  day. 

42.  Sept.  22,  1903.  E.  S.  134181.  Male— 8  mos.  Double  deep  cervical  ab- 
scess, opened  by  House  Surgeon  under  E.  A.  C.'s  direction.  Complica- 
tions; severe  diarrhoea.    Died  on  9th  day.    Wounds  O.  K. 

43.  Feb.  25,  1906.  S.  S.  146574.  Male  child— 9  mos.  Abdom.  pain  and  fever 
for  4  days.  Op.  E.  A.  C. — Negative  abdom.  exploration.  Died  suddenly 
next  day.    Autopsy  showed  acute  pericarditis  and  status  lymphaticus. 

44.  Dec.  24,  1906.  E.  S.  558-215.  Alcoholic  male— 38.  Abscess  of  neck. 
Operated  on  by  House  Surgeon  under  E.  A.  C.'s  direction.  Delirium 
tremens.    Death  on  6th  day. 

45.  Jan.  7,  1907.  E.  S.  150980.  Female — 34.  Severe  epigastric  pain  and 
vomiting  for  3  days.  Obese  woman  in  profound  collapse.  Op.  E.  A.  C. 
— Distended  bowels.  No  cause  for  obstruction  found.  Enterostomy. 
Died  a  few  hours  later.  Autopsy:  Acute  pancreatitis.  Impacted  stone 
in  ampulla. 

46.  Jan.  1,  1908.  E.  S.  156570.  Female— 54.  Abdom.  pain  for  2  weeks. 
Op.  E.  A.  C. — Multiple  abdominal  adhesions  found.  Nothing  done. 
Healing  by  first  intention.  Transferred  to  medical  on  34th  day,  under 
diagnosis  of  acute  endocarditis.    Died  5  days  later.    No  autopsy. 

47.  Dec.  19,  1911.  E.  S.  180030.  A  girl  of  5  yrs.  Abdom.  pain  fori  week. 
Op.  E.  A.  C. — Cloudy  fluid,  peritoneum  red  and  injected;  appendix 
adherent  and  strictured,  but  not  acute.  Culture  showed  pneumococci. 
Died  on  8th  day. 

48.  Aug.  8,  1913.  E.  S.  190582.  Male— 25.  Very  acute  abdom.  pain  54  hrs. 
Op.  E.  A.  C. — Free  bloody  fluid.  Hard  hemorrhagic  pancreas  incised 
and  drained.  Died  on  33d  day  of  acute  mania(?).  Autopsy  showed 
that  pancreas  had  entirely  sloughed  away. 

49.  Feb.  20,  1914.  E.  S.  884-67.  Colored  male — 48.  Agonizing  abdom.  pain 
for  2  days.  Op.  E.  A.  C. — Greatly  enlarged  left  lobe  of  liver  presented. 
I  considered  it  gumma  and  closed  the  abdomen.  Patient  was  trans- 
ferred to  care  of  another  surgeon,  and  died  on  7th  day  with  symptoms 
strongly  suggesting  abscess  of  liver.  Wasserman  negative.  Wound 
clean, 

146 


OTHER  CONDITIONS 

SKULL  FRACTURES 

50.  Aug.  8,  1901.  E.  S.  394-56.  Male— 43.  Fell  off  roof.  Comatose.  Frac- 
ture of  base  of  skull.  Op.  E.  A.  C. — Trephined  and  clot  evacuated. 
Died  same  day. 

51.  Sept.  28,  1901.  E.  S.  396-32.  Male — 4.  Fell  from  iire  escape.  Uncon- 
scious. Op.  E.  A.  C. — Raising  depressed  fracture  of  skull.  Died  next 
day  without  having  recovered  consciousness. 

52.  Nov.  18,  1905.  E.  S.  145249.  Male—?.  R.  R.  accident.  Multiple  in- 
juries and  depressed  fracture  of  skull.  Op.  E.  A.  C. — Elevation  of 
depressed  fragment;  puncture  lateral  ventricle.  Died  same  day. 
Autopsy:  Intra-peritoneal  hemorrhage  from  ruptured  liver,  kidney,  and 
adrenal. 

63.  Jan.  26,  1907.  E.  S.  560-191.  Male— 32.  Brought  in  unconscious. 
Vague  history  of  fall.  Op.  E.  A.  C. — Exploratory  craniotomy — nega- 
tive. Died  next  day.  Autopsy:  Hemorrhage  from  aneurysm  of  middle 
cerebral  artery.    Tuberculosis  of  lungs. 

54.  Nov.  2,  1907.  E.  S.  155538.  Male— 24.  Fell  off  running-board  of  car. 
Comatose.  Op.  E.  A.  C. — Trephined.  Subdural  hemorrhage.  Fracture 
of  base.    Died  same  day. 

55.  Sept.  9,  1908.  E.  S.  160174.  Male— 31.  Fell  on  head;  bleeding  from 
mouth;  convulsions.  Op.  E.  A.  C. — Negative  exploratory  craniotomy. 
Died  4  days  after  op.  Delirium  tremens.  Autopsy:  Cyst  of  brain, 
mitral  disease,  etc. 

56.  Jan.  11,  1909.  E.  S.  161930.  Male — 40.  Injuries  following  epileptic 
attack  in  a  drunkard.  Unconscious.  Convulsions.  Op.  E.  A.  C. — Ex- 
ploratory craniotomy.  Fracture  temporal  bone.  Brain  had  dark,  bloody 
appearance.    Regained  consciousness  for  24  hrs.,  but  died  2  days  later. 

57.  Jan.  3,  1911.  E.  S.  173779.  Male— 23.  R.  R.  accident.  Shock.  Coma. 
Multiple  injuries.  Comp.  fracture  of  tibia  and  fibula.  Depressed  frac- 
ture of  skull.  Op.  E.  A.  C. — Raising  depressed  fracture.  Died  same 
day  without  recovering  consciousness. 

Note. — I  believed  and  still  believe  in  operation  on  every  case  with  severe 
symptoms,  of  fracture  of  the  base.  Several  successful  cases  will  be  found 
in  the  records. 

CRUSHED  OR  SEPTIC  LEGS  (AMPUTATION) 

68.  May  2,  1901.  E.  S.  386-162.  Male— 26.  Run  over  by  express  wagon. 
Comp.  fracture  of  tibia.  Operated  on  by  House  Surgeon  and  bone 
wired.  Later  sepsis  and  pyemia.  Op.  E.  A.  C. — Amputation  at  knee. 
Death  from  pyemia  on  19th  day. 

69.  Sept.  20,  1902.  E.  S.  129234.  Male— 22.  Compound  fracture  of  thigh 
and  internal  injuries.  Op.  by  House  Surgeon,  under  direction  of  E.  A. 
C.    Thigh  amputation.    Died  same  day. 

60.  Jan.  8,  1903.  E.  S.  425-147.  Male— 27.  R.  R.  accident.  Both  legs 
crushed.  Multi))le  injuries,  including  fractures  of  humerus  and  ulna. 
Op.  E.  A.  C. — Amputation  both  legs  and  one  arm.    Died  next  day. 

61.  May  19,  1903.  E.  S.  444-1.  Male — 40.  Charcots  knee-joint,  which  had 
been  excised  by  another  surgeon  and  followed  by  severe  sepsis.  Op. 
E.  A.  C— Thigh  amputation.  Death  on  12th  day  from  sepsis  and 
exhaustion. 

62.  May  12,  1904.  S.  S.  137328.  Male— 21.  Both  legs  crushed  in  R.  R. 
accident.  Op.  E.  A.  C — Rt.  thigh  amputation.  Left  leg  amputation. 
Death  same  day. 

147 


63.  Jan.  2,  1906.  E.  S.  1458.50.  Male — 55.  Osteomyelitis  of  femur,  previ- 
ously operated  on  bj'  several  otiier  surgeons.  Severe  sepsis  from  l\nee- 
joint  to  groin.    Op.  E.  A.  C. — Tiiigh  amputation.    Died  soon  after  op. 

64.  Jan.  5,  1910.  E.  S.  1G7717.  Male— 33.  R.  R.  accident.  Traumatic 
amputation  both  legs  and  left  arm.  Op.  E.  A.  C. — Direct  transfusion. 
Died  while  transfusion  was  being  done. 

MULTIPLE  INJURIES 

65.  Dec.  6,  1907.  E.  S.  156021.  Male— 25.  Crushed  by  locomotive  wheel. 
Op.  E.  A.  C. — Irrigation  and  cleaning  of  extensive  lacerations  of  scro- 
tum, perineum,  thigh,  and  buttocks.    Died  same  day. 

66.  Nov.  2,  1908.  E.  S.  160961.  Male— 43.  Fell  from  roof.  Fracture  left 
ribs,  clavicle,  and  left  Colles  fracture.  Intra-thoracic  hemorrhage.  Op. 
E.  A.  C. — Negative  exploratory  laparotomy  for  suspected  abdominal 
hemorrhage.    (Cocaine.)    Died  same  day. 

67.  Jan.  9,  1910.  E.  S.  672-75.  Male— 28.  Run  over  by  electric  car.  Lacer- 
ated wounds  of  left  arm,  hand,  lower  abdomen,  uretlira,  and  testicle. 
By  direction  of  E.  A.  C.  on  telephone,  the  House  Surgeon  cleaned  up 
all  the  wounds  with  great  care.  The  patient  died  6  days  later  with 
sepsis,  sloughing,  delirium,  and  pneumonia. 

TRAUMATIC  TETANUS 

68.  Jan.  28,  1900.  E.  S.  374-58.  Male — 11.  Blank  cartridge  wound  of  hand 
10  days  before.  Tetanus.  Op.  E.  A.  C. — Powder  and  wadding  excised 
with  ragged  tissue  from  hand.  Wound  packed.  Antitoxin.  Died  on 
5th  day. 

69.  July  11,  1900.  E.  S.  374-118.  Male— 17.  Blank  cartridge  wound  of 
hand.  Tetanus.  Op.  E.  A.  C — Antitoxin  injected  in  both  lateral  ven- 
tricles through  small  trephine  holes.    Died  next  day. 

70.  Aug.  20,  1900.  E.  S.  376-10.  Male— 33.  Tetanus  following  rusty  nail 
wound  in  foot  6  days  before.  Op.  E.  A.  C. — Wound  in  foot  excised  and 
both  lateral  ventricles  injected  with  antitoxin.    Death  next  day. 

71.  Dec.  10,  1909.  E.  S.  670-95.  Male— 16.  Revolver  wound  of  palm  of 
hand  7  days  before.  Tetanus.  Op.  by  House  Surgeon,  under  direction 
of  E.  A.  C.  Excision  of  wound  of  hand  with  paper  wad.  Antitoxin. 
Later  another  surgeon  excised  the  axillary  glands.   Death  on  6th  day. 

FRACTURED  SPINE 

72.  Aug.  4,  1900.  E.  S.  372-168.  Female— 34.  Fell  from  bleachers.  Com- 
plete paralysis  below  nipples.  Op.  E.  A.  C. — Laminectomy  3-5  dorsal. 
Found  cord  completely  severed.  Died  suddenly  as  she  was  lifted  from 
operating  table. 

73.  Feb.  21,  1906.  S.  S.  146521.  Male— 38.  Fell  30  feet.  Fract.  5th  cervical 
vertebra.  Op.  E.  A.  C. — Laminectomy.  Became  cyanotic  and  died  on 
2d  day. 

RUPTURED  OR  PERFORATED  VISCERA 

74.  Aug.  18,  1900.  E.  S.  376-2.  Male— 42.  24  hrs.  before,  struck  abdomen 
on  fence  post  when  walking  fast  in  dark.  General  peritonitis.  Feces 
in  abdominal  cavity.  Ruptured  intestine  found  and  closed.  Died  next 
day. 

76.  Male — 28.  Had  been  operated  on  by  another  surgeon  4  weeks  previ- 
ously for  acute  appendicitis  and  general  peritonitis.  A  sponge  iiad 
been  left  in  the  abdomen.  Op.  by  E.  A.  C.  under  diagnosis  of  residual 
abscess.  Abscess  cavity  which  communicated  with  intestine  found,  and 
sponge  removed.    Died  soon  afterward  with  fecal  fistula. 

148 


76.  Dec.  25,  1901.  S.  S.  60-16.  Male— 51.  Sudden  abdom.  pain  and  signs 
of  peritonitis.  Op.  E.  A.  C— Peritonitis  due  to  perforation  of  cancer 
of  stomach.    Gastroenterostomy.    Died  on  4th  day. 

77.  July  21,  1902.  E.  S.  390-220.  Male — iO.  Gunshot  wound  of  arm,  chest, 
and  abdomen.  Kidney  and  lung  perforated.  Op.  E.  A.  C— Laparotomy. 
Blood  found  in  abdominal  cavity,  but  no  organ  seemed  to  be  wounded 
except  kidney.  As  bleeding  along  drainage  tract  continued,  a  second 
operation  was  done  which  demonstrated  punctate  hemorrhages  in  in- 
testine, probably  from  wound  of  mesenteric  vessels.  Enterostomy. 
Death  on  2d  day. 

78.  Aug.  27,  1902.  E.  S.  418-83.  Male— 4.  Abdominal  injury  from  wagon. 
Op.  E.  A.  C— Abdomen  full  of  blood  from  bleeding  mesentery,  which 
had  been  torn  from  intestinal  attachment.    Died  same  day. 

79.  Oct.  29,  1902.  W.  S.  129632.  Male— 21.  Perforated  typhoid  ulcer. 
Op.  E.  A.  C— Exploration  with  cocaine  followed  by  ether.  Perforation 
found  and  closed.  Died  on  3d  day.  Autopsy  showed  a  second  perfora- 
tion and  peritonitis. 

80.  Aug.  23,  1903.  E.  S.  183774.  Male— 37.  Perforated  duodenal  ulcer 
with  general  peritonitis.  Op.  E.  A.  C.— Perforation  closed.  Drainage. 
Later  two  secondary  operations  were  done  by  E.  A.  C,  one  for  sub- 
diaphragmatic abscess  and  one  for  pelvic  abscess.  Still  later,  another 
surgeon  operated  for  intestinal  obstruction.  The  patient  died  10  days 
after  this,  two  months  after  my  first  operation.  (I  believe  this  to  have 
been  the  first  case  of  perforated  duodenal  ulcer  recognized  at  opera- 
tion and  closed  by  suture  at  the  hospital.) 

81.  Sept.  25,  1903.  E.  S.  134230.  Female — 65.  Peritonitis  from  perforated 
gastric  cancer.  Op.  E.  A.  C. — Partial  gastrectomy,  gastroenterostomy; 
drainage.    Died  on  3d  day. 

82.  Oct.  15,  1905.  E.  S.  144614.  Male— 9.  Perforated  typhoid  ulcer.  Op. 
E.  A.  C— Suture  perforation.  Died  on  13th  day.  Necrosis  of  suture 
line  with  abscess. 

83.  Dec.  30,  1905.  E.  S.  145792.  Male— 37.  General  peritonitis  from  rup- 
tured bladder.  Op.  E.  A.  C — Free  pus  in  peritoneum.  Bladder  small 
and  wilted.    Drainage.    Died  same  day. 

84.  Jan.  4,  1906.  E.  S.  145839.  Male— 50.  Abdom.  pain  and  vomiting  for 
5  days.  In  medical  ward  2  days  without  surgical  consultation.  Op. 
E.  A.  C. — General  peritonitis.  Drainage.  Cause  not  searched  for,  as 
condition  too  poor.  Died  same  day.  Autopsy  showed  a  perforation  of 
a  diverticulum  of  Ileum,  strictures  of  intestine,  general  peritonitis,  etc. 

85.  Dec.  22,  1907.  E.  S.  156279.  Male— 49.  Abdom.  pain  and  vomiting 
5  days.  Much  worse  last  12  hrs.  General  peritonitis.  Op.  E.  A.  C. — 
Suture  of  perforated  duodenal  ulcer  and  drainage.    Died  soon  after  op. 

86.  Dec.  13,  1909.  E.  S.  167351.  Male — 49.  Blow  on  abdomen  4  days  be- 
fore. Op.  E.  A.  C— Peritonitis  in  right  iliac  region,  where  an  ecchy- 
mosed  coil  of  intestine  was  firmly  adlierent.  In  freeing  it,  it  was  rup- 
tured. Excision  of  damaged  six  inches.  Enterostomy.  Death  on  4th 
day,  shortly  after  wound  had  broken  open  from  distention. 

87.  Nov.  13,  1910.  E.  S.  172960.  Male — 40.  Perforated  duodenal  ulcer. 
Patient  in  desperate  condition  from  several  months'  illness  with  hemor- 
rhages and  obstruction.  Op.  E.  A.  C— Peritonitis.  Closure  perforation 
and  drainage.  Later  a  jejunostomy  under  cocaine.  Died  on  8th  day. 
Autopsy:  Tuberculosis  of  lungs  with  cavity  formation.  Tuberculous 
peritonitis.    Tuberculous  ulcers  of  duodenum,  etc. 

88.  Dec.  5,  1911.  W.  S.  179789.  Male— 4.  Abdom.  pain  48  hrs.  General 
peritonitis.  Op.  E.  A.  C — Suture  of  perforation  of  gastric  ulcer,  and 
drainage.    Died  same  day. 

149 


89.  Feb.  8,  1912.  E.  S.  184939.  Female— 26.  Abdom.  pain  2  days.  General 
peritonitis.  Op.  E.  A.  C. — Abdomen  full  of  stomach  contents.  Perfora- 
tion in  duodenum  closed.    Drainage.    Died  in  24  hrs. 

90.  Mar.  3,  1912.  E.  S.  181351.  Male— 17.  Abdomen  injured  in  coasting 
24  hrs.  before.  Op.  E.  A.  C. — General  peiit'^nitis.  Nearly  complete 
transverse  rupture  of  intestine.  Lavage.  Double  enterostomy  in  ends 
of  rupture.    Died  in  48  hrs. 

91.  Jan.  10,  1913.  E.  S.  187040.  Male— 40.  Perforated  duodenal  ulcer 
with  general  peritonitis.  Op.  E.  A.  C. — Closure  of  perforation  and 
gastroenterostomy.  Delirium  tremens.  Death  on  3d  day.  Abdomen  in 
good  condition. 

92.  Feb.  26,  1913.  E.  S.  187822.  Male— 29.  Perforated  duodenal  ulcer  and 
peritonitis.  Op.  E.  A.  C. — Closure  of  perforation.  Appendectomy. 
Death  on  2d  day  from  hematemesis.  Autopsy  showed  the  hemorrhage 
had  come  from  another  duodenal  ulcer. 

Note. — Bad  as  these  cases  were,  the  records  will  show  that  I  saved  other 
similar  ones. 

STRANGULATED  HERNIA 

93.  Aug.  24,  1901.  E.  S.  392-116.  Female — 42.  Femoral  hernia,  strangu- 
lated 4  days.  Op.  E.  A.  C. — Resection  gangrenous  bowel.  End-to-end 
anastomosis.    Died  next  day. 

94.  Dec.  13,  1901.  E.  S.  400-80.  Male— 57.  Inguinal  hernia,  strangulated 
12  hrs.  Op.  E.  A.  C. — Local  anaesthesia.  Four  inches  of  black  bowel 
with  adjacent  Meckel's  diverticulum  resected.  Lateral  anastomosis  and 
enterostomy  in  proximal  end.    Death  on  3d  day. 

95.  Sept.  16,  1902.  E.  8.  129024.  Male— 43.  Strangulated  umbilical  hernia. 
Op.  E.  A.  C. — Many  coils  in  sac.  One  coil  10  inches  long  completely 
gangrenous.  Free  pus  in  abdomen.  Excision  gangrenous  gut  and  en- 
terostomy.   Death  in  24  hrs. 

96.  Sept.  20,  1903.  E.  S.  134148.  A  new-born  baby  with  a  malformation 
of  abdomen,  so  that  most  of  intestine  and  liver  were  in  the  sac  of  an 
umbilical  hernia.  Op.  E.  A.  C. — Organs  replaced  and  sac  closed.  Death 
in  24  hrs. 

97.  May  3,  1905.  S.  S.  142437.  Male— 68.  Inguinal  hernia  of  long  stand- 
ing; strangulated  for  12  hrs.  Op.  E.  A.  C. — Many  adhesions  in  sac. 
Gut  viable;  returned  to  abdomen.  Died  on  2d  day  of  double  pneumonia. 

98.  Nov.  26,  1906.  E.  S.  150431.  Corpulent  female— 52.  Strangulated 
umbilical  hernia  for  4  days.  Op.  E.  A.  C — Viable (.')  gut  returned. 
Vomiting  continued.    Death  on  2d  day. 

99.  Jan.  11,  1907.  E.  S.  151052.  Male— 26.  Strangulated  inguinal  hernia 
for  5  days.    Op.  E.  A.  C. — Enterostomy.    Died  next  day. 

100.  Dec.  6,  1910.  E.  S.  173325.  Female— 50.  Laparotomy  by  another  sur- 
geon in  1898.  In  1907,  op.  by  still  another  surgeon  for  hernia  in  scar. 
Came  in  with  hernia  in  scar  strangulated  for  48  hrs.  Op.  E.  A.  C. — 
Multiple  adhesions  freed  and  a  viable(?)  coil  of  dark  red-brown  intes- 
tine reduced.  Died  soon  after  operation.  Autopsy  showed  syphilitic 
aortitis,  chronic  meningitis,  hypertrophy,  and  dilatation  of  heart,  etc. 

Note. — Perhaps  enterostomy  and  washing  of  inside  of  gut  might  have 
saved  some  of  these. 

TUBERCULOUS  PERITONITIS 

101.  June  12,  1903.  E.  S.  132G68.  Female— 35.  Entered  as  emergency. 
12  days'  abdom.  pain  and  vomiting.  Op.  E.  A.  C— Diffuse  tuberculous 
peritonitis.  Washed  witii  salt  solution  and  wound  closed.  Wound  clean. 

150 


Two  secondary  operations  were  done  by  E.  A.  C.  to  drain  absces'^es. 
In  one  of  tiiese  the  bowel  was  nicked  and  a  fecal  fistula  developed. 
Later  another  surgeon  attempted  (against  my  urgent  advice)  to  clocc 
the  fistula.    Death  soon  after.    This  was  3  mos.  after  first  operation. 


TRANSFUSION  FOR  RUPTURED  LIVER 

102.  Feb.  5,  1908.  W.  S.  156904.  Male— 18.  Multiple  injuries.  Intra-ab- 
dominal hemorrhage  from  ruptured  liver,  fractured  skull,  etc.  Shock. 
Op.  E.  A.  C. — Direct  transfusion  by  Crile  method.  Laparotomy  by 
S.  J.  Mixter.  Ruptured  liver  packed  with  gau'e.  Patient  was  put  in 
good  condition  by  transfusion,  but  died  on  the  8th  day  of  sepsis  in  the 
abdominal  wound.  Autopsy  showed  ruptured  liver,  hydrothorax,  car- 
diac insufficiency,  splenic  tumor,  thrombosis  of  portal  vein,  skull  frac- 
tured in  right  temporal  region  and  base,  peritonitis. 

OPERATIONS  FOR  CANCER  OF  STOMACH 

103.  Jan.  6,  1910.  E.  S.  672-35.  Male — 46.  Severe  gastric  symptoms.  Op. 
E.  A.  C. — Excision  of  large  indurated  ulcer  of  lesser  curvature 
(cancer).  When  the  suture  was  completed,  the  stomach  was  a  mere 
contracted  tube.  Gastrostomy  was  done,  so  that  a  catheter  could  be 
left  in  the  duodenum.  The  patient  improved  for  2  weeks,  when  the 
wound  broke  down,  and  he  died  on  the  17th  day.  Autopsy:  Broncho- 
pneumonia and  lung  abscess.    Septic  wound. 

104.  Mar.  1,  1913.  E.  S.  187691.  Male— 52.  Had  been  operated  on  4  yrs. 
previously  by  another  surgeon  for  same  symptoms.  A  cholecystostomy 
had  been  done  for  supposed  cholecystitis.  Relief  was  only  temporary. 
When  seen  by  me  he  was  anemic,  emaciated,  with  typical  symptoms 
of  cancer  of  stomach.  Op.  E.  A.  C. — Partial  gastrectomy  with  gall 
bladder,  which  was  adherent  in  mass.  Died  5  days  later.  Autopsy 
showed  metastatic  glands,  peritonitis,  etc. 

105.  May  14,  1913.  E.  S.  189130.  Male— 60.  Symptoms  suggesting  ulcer  or 
cancer  of  stomach.  Op.  E.  A.  C. — A  large  indurated  ulcer,  high  on 
lesser  curvature,  adherent  to  pancreas  (probably  cancer).  Ant.  gas- 
troenterostomy and  enteroenterostomy.  Died  on  5th  day.  Pulmonary 
embolus  and  nephritis. 

106.  July  7,  1913.  E.  S.  19005.  Male— 30.  A  case  which  had  lain  for  weeks 
in  the  medical  wards,  with  severe  gastric  hemorrhages ;  had  been  trans- 
fused. I  had  watched  for  a  favorable  opportunity  to  operate.  Failure 
of  medical  treatment.  Op.  E.  A.  C. — Large  ulcer  (probably  cancer) 
of  lesser  curvature  adherent  to  pancreas.  Gastroenterostomy  satisfac- 
torily completed  under  local  anaesthesia.  Transfusion  (indirect)  by 
another  surgeon.    Suddenly  died  during  transfusion. 

107.  July  19,  1913.  E.  S.  190225.  An  emaciated  man  of  63,  with  severe 
gastric  symptoms.  Op.  E.  A.  C. — Large  mass  on  lesser  curvature. 
Local  anaesthesia.  Gastroenterostomy.  Died  in  medical  ward  a  month 
later  from  pulmonary  condition.  Autopsy:  Cancer  with  metastases. 
Pneumonia  and  abscess  of  lung. 

108.  Sept.  8,  1913.  E.  S.  191105.  Male—?.  Symptoms  of  cancer  of  stomach. 
Op.  E.  A.  C. — Partial  gastrectomy  for  cancer  of  pyloric  end.  Suddenly 
died  on  4th  day  of  pulmonary  embolus  (?). 

109.  Dec.  2,  1913.  E.  S.  870-331.  Male— 25.  An  obscure  abdom.  emergency. 
Oi).  E.  A.  C. — Liver  full  of  soft  knobs.  One  tapped  with  trochar  and 
bit  excised  for  path.  exam.  Died  same  night.  Autopsy:  Cancer  of 
stomach  and  liver,  and  peritonitis. 

151 


OTHER  OPERATIONS  FOR  CANCER 

110.  Aug.  16,  1902.  E.  S.  410-245.  Female— 52.  Extensive  cancer  of  uterus. 
Op.  E.  A.  C. — Total  hysterectomy  and  radical  pelvic  dissection,  using 
Crile  clamps  on  int.  iliac  arteries.  Comp. — Thrombosis  of  external  iliac 
artery.  On  5th  day  op.  E.  A.  C. — Thigh  amputation  for  gangrene.  Died 
soon  after. 

111.  Aug.  23,  1902.  E.  S.  128665.  Female— 36.  Extensive  cancer  of  uterus. 
Op.  E.  A.  C. — Total  hysterectomy  and  radical  pelvic  dissection.  Bladder 
and  ureter  involved.  Comp. — Urinary  fistula,  and  later  recto-vaginal 
fistula.    Died  3  weeks  later. 

112.  June  6,  1900.  E.  S.  372-38.  Female— 73.  Cancer  of  breast.  Op.  E.  A. 
C. — Amputation  of  breast  and  dissection  of  axilla.  Died  of  pneumonia 
on  7th  day.    Wound  .lean. 

113.  July  16,  1902.  E.  S.  412-239.  Male— 58.  Extensive  cancer  of  lower 
jaw.  Op.  E.  A.  C. — Excision  of  almost  whole  lower  jaw  back  to  angles. 
Tongue  suspended  with  silver  wire.  Died  suddenly  about  3  weeks  later 
of  pulmonary  complications — probably  embolism. 

114.  Jan.  5,  1906.  E.  S.  161772.  Female— 43.  Prolapse  of  uterus  and  abdom. 
tumor  (ovarian).  Op.  E.  A.  C. — Removal  of  tumor  size  of  child's  head 
(sarcoma),  with  3  loops  of  involved  intestine.  End-to-end  anastomoses. 
Died  next  day.    Peritonitis  and  other  lesions. 

115.  Sept.  24,  1906.  E.  S.  149612.  Male— 75.  Extensive  cancer  of  lip.  Op. 
E.  A.  C. — Removal  of  whole  lower  lip  and  dissection  of  both  sides  of 
neck.  Died  2  days  after  operation.  Autopsy:  Pneumonia.  Cysts  of 
kidneys.    Hypertrophy  and  dilatation  of  heart.    Wound  clean. 

116.  Apr.  13,  1909.  E.  S.  163383.  Female— 59.  This  patient  was  given  up 
as  inoperable  by  another  surgeon  in  Mar.,  1904.  She  had  extensive 
cancer  of  the  face,  involving  the  whole  nose  and  both  lower  eyelids. 
Between  this  date  and  1909,  I  operated  on  her  8  times — each  time  excis- 
ing portions  of  her  facial  bones  and  covering  in  the  defects  with  flaps 
from  the  cheek  and  neck.  Each  operation  made  her  presentable  for  a 
few  months,  and  she  would  return  when  recurrence  took  place.  At  the 
final  operation  I  removed  what  remained  of  both  upper  jaws.  She  died 
the  same  night.    (See  Bibliography.) 

117.  Jan.  27,  1910.  E.  S.  167909.  Male— 45.  Symptoms  suggesting  cancer 
of  stomach.  Op.  E.  A.  C. — A  papillary  adenoma  of  the  duodenal  papilla 
size  of  horse-chestnut.  Excision  and  cauterization  of  base.  Cholecyst- 
duodenostomy  to  insure  drainage  of  bile  into  intestine.  Died  on  6th 
day.  Sepsis  and  hemorrhage.  Autopsy:  Old  tuberculosis  both  lungs, 
etc. 

COMPLICATED  OR  ACUTE  GALLSTONE  CASES 

118.  Sept.  9,  1901.  E.  S.  392-152.  Female— 53.  Violent  abdom.  pain,  jaun- 
dice, and  signs  of  peritonitis.  Op.  E.  A.  C. — General  peritonitis.  Dis- 
tended gall  bladder.  Distended  intestines.  Enterostomy.  Died  in  24 
hrs.  (probably  acute  gall  bladder). 

119.  July  11,  1902.  E.  S.  128004.  Female— 36.  Had  previously  been  oper- 
ated on  (Aug.,  1901)  by  E.  A.  C.  and  7  large  gallstones  removed  from 
gall  bladder.  Returned  with  jaundice  and  severe  attacks  of  pain 
(abuse  of  morphine).  Op.  E.  A.  C. — Cholecystectomy;  gall  bladder 
contained  more  gallstones  of  entirely  different  shape  and  color  from 
those  first  removed.  Died  on  20th  day  from  exiiaustion  due  to  excessive 
fluid  drainage  from  duct. 

120.  Aug.  19,  1902.  E.  S.  128602.  Female— 41.  An  emergency  case,  with 
typical  gallstone  symptoms  and  jaundice.  Op.  E.  A.  C. — Gall  bladder 
contained  viscid  fluid  and  small  stones.  Nothing  felt  in  duct.  Chole- 
cystostomy.    After  operation   tliere   were  symptoms  of  common  duct 

152 


obstruction, — all  bile  came  through  wound,  and  stools  were  clay-colored. 
At  second  operation,  no  cause  for  obstruction  was  found  and  a  chole- 
cystenterostomy  was  done.    Death  30  days  after  first  operation. 

121.  June  15,  1903.  E.  S.  132686.  Female— 50.  Deep  jnundice  and  other 
severe  symptoms  of  gallstones.  Op.  E.  A.  C. — Cholecystectomy  and 
removal  of  stone  in  common  duct.  Drainage  of  small  abscess  of  liver. 
Death  on  14th  day.  At  autopsy  a  sponge  was  found  in  the  open  wound 
in  contact  with  the  wick. 

122.  Dec.  26,  1905.  E.  S.  145736.  Female — 34.  Jaundice  and  other  severe 
symptoms.  Op.  E.  A.  C. — Choledochoduodenostomy.  A  very  large 
stone  removed  from  papilla  and  others  from  common  duct  and  gall 
bladder.    Died  on  11th  day. 

123.  Jan.  2,  1907.  E.  S.  150917.  Female — 52.  Had  been  operated  on  a  year 
previously  by  another  surgeon;  some  stones  were  removed  from  the 
gall  bladder.  Returned  with  pain  and  jaundice.  Op.  E.  A.  C. — Stone 
removed  from  common  duct,  etc.    Died  on  19th  day.    Pneumonia,  etc. 

OPERATIONS  FOR  VARIOUS  OTHER  CONDITIONS 

124.  Feb.  12,  1906.  E.  S.  146396.  Female— 39.  Seven  months  ago  slight 
attack  of  abdom.  pain,  more  marked  on  right  side.  Not  confined  to  bed. 
Six  months  ago  similar  attack,  but  much  more  severe.  In  bed  2  weeks. 
Tenderness  over  appendix.  Op.  E.  A.  C. — Appendix  twisted,  somewhat 
enlarged,  and  adherent  to  cecum.  Ileum  somewhat  adherent  to  other 
bowels  and  posterior  peritoneum.  Appendectomy.  The  patient  died 
48  hrs.  later.  Death  was  unexplained.  There  was  distention,  black 
vomit,  and  cyanosis. 

Note. — These  notes  are  taken  from  the  record.  I  have  no  recollection  of 
this  case,  although  I  remember  nearly  all  the  others.  I  must  have  failed 
entirely  to  find  the  lesion  which  was  the  cause  of  her  death.  The  case  is 
catalogued  as  "chronic  appendicitis."  Possibly  it  was  acute  peritonitis  from 
post-operative  infection,  but  I  think  not.  It  was  an  exploratory  operation 
in  the  course  of  wliich  the  appendix  was  removed,  and  it  should  not  be 
classed  as  death  from  "appendectomy." 

125.  Jan.  1,  1908.  E.  S.  156415.  Male— 1.  Extreme  deformities  of  lip  and 
palate.  The  double  harelip  and  protruding  maxillary  bones  were  suc- 
cessfully operated  on  by  E.  A.  C.  in  Oct.,  1907,  and  the  cleft  palate 
pperation  postponed  until  Jan.,  1908.  Op.  E.  A.  C. — Radical  cleft 
palate  operation  apparently  very  successful.  The  child  died  next  day 
of  acetonemia(?).    (Probably  op.  hemorrhage.) 

126.  Nov.  10,  1908.  E.  S.  624-221.  Female— 37.  Operated  on  3  yrs.  before 
by  another  surgeon  for  fibroid  of  uterus.  Ventral  hernia  in  scar.  Chr. 
phlebitis  of  leg.  Chr.  cough.  Kept  in  bed  a  week  for  temp.  (102)  and 
cough  to  quiet  down.  Op.  E.  A.  C. — Radical  cure  of  ventral  hernia. 
Cough  increased  at  once  after  op.    Died  on  3d  day.    Pneumonia. 

127.  Nov.  12,  1908.  W.  S.  161115.  Male— 4.  Ciccatrix  from  burn  of  neck 
and  chest,  causing  great  deformity.  Neck  was  obliterated  and  chin 
drawn  down  to  sternum.  Op.  E.  A.  C. — Extensive  plastic  and  excision 
of  scar  tissue.    Died  on  17th  day  from  pneumonia  and  sepsis. 

128.  Nov.  21,  1908.  E.  S.  630-151.  Male— 7.  Advanced  cirrhosis  of  liver. 
Op.  E.  A.  C. — Abdom.  exploration  and  evacuation  of  ascitic  fluid. 
Erysipelas  of  face.  Later  another  operation — omentopexy.  Died  on 
6th  day. 

129.  Nov.  12,  1909.  E.  S.  166890.  Male— 39.  Enormous  renal  calculi  in  both 
kidneys.  In  Jan.,  1909,  E.  A.  C.  had  removed  a  stone  weighing  220 
grams  (I  think  the  largest  on  record  in  this  vicinity)  from  left  kidney, 
and  sent  patient  home  to  recuperate  before  operating  on  right  kidney. 

153 


He  returned  in  poor  condition.  Op.  E.  A.  C. — Nephrotomy  (rt.)  and 
removal  of  stones  nearly  as  large  as  the  one  from  the  other  side. 
Death  on  14th  day. 

130.  Dec.  7,  1909.  E.  S.  167264.  Female— 37.  Multiple  abdom.  and  pelvic 
symptoms  and  uterine  displacement  and  lacerations.  Op.  E.  A.  C. — 
Uterus  dilated  and  curetted.  Trachelorrhaphy,  perineorrhaphy,  appen- 
dectomy, ventral  fixation.  Death  on  Gth  day.  Autopsy  showed  a  variety 
of  lesions,  including  gallstones  and  pneumonia.    Wounds  O.  K. 

131.  Aug.  11,  1900.  E.  S.  374-222.  Male— 45.  Multiple  strictures  of  urethra, 
and  periurethral  abscess.  Urinary  incontinence  8  yrs.  Op.  E.  A.  C — 
External  and  internal  urethrotomy.  Sudden  death  on  14th  day.  Cause 
unknown. 

132.  Jan.  27,  1909.  E.  S.  636-139.  Male— 49.  Stricture  of  urethra.  Op. 
E.  A.  C. — Perineal  section.  Post-operative  bronchitis.  Sudden  death 
on  36th  day.    No  autopsy. 

133.  Jan.  2,  1907.  E.  S.  150920.  Female— 63.  In  desperate  condition  from 
trifacial  neuralgia.  Had  had  previous  peripheral  operations.  Op.  E. 
A.  C. — Total  extirpation  of  Gasserian  ganglion.  Death  on  2d  day. 
Pneumonia  and  meningitis ( ?). 

134.  July  21,  1902.  E.  S.  412-273.  Male— 26.  Hydrocele,  varicocele,  and 
double  hernia.  Op.  E.  A.  C. — Radical  cure  of  above.  Pneumonia  fol- 
lowed the  operation,  and  he  was  transferred  to  medical  ward.  All 
wounds  healed  by  first  intention,  but  patient  died  on  45th  day. 

Note. — The  above  ten  cases  are,  in  my  opinion,  those  most  subject  to 
adverse  criticism. 

GASTRIC  AND  DUODENAL  ULCER 
(all  perforated,  but  adherent) 

135.  Jan.  23,  1910.  E.  S.  167863.  Male— 42.  Post,  gastroenterostomy  had 
been  done  for  duodenal  ulcer  in  June,  1905,  by  another  surgeon.  Relief 
for  nearly  4  yrs.,  when  symptoms  recurred  with  increasing  severity. 
Persistent  vomiting,  iiemorrhages,  stasis,  and  dilatation.  Op.  E.  A.  C. 
— Stomach  greatly  dilated.  Both  pylorus  and  stoma  contracted  so  as 
to  be  practically  impassible.  Ant.  gastroenterostomy  to  another  loop. 
Patient  continued  to  have  hemorrhages  and  died  on  7th  day.  Autopsy 
showed  active  duodenal  ulcer  and  contracted  stoma  of  former  gastro- 
enterostomy, with  ulceration  and  a  Pagenstecker  thread  hanging  in 
lumen.    Broncho-pneumonia. 

136.  Jan.  23,  1910.  E.  S.  167784.  Male^lO.  Typical  duodenal  ulcer  symp- 
toms, worse  recently.  Op.  E.  A.  C. — A  hard,  matted  mass  near  pylorus 
in  duodenum — evidently  perforation  which  had  been  closed  by  adhe- 
sions. Gastroenterostomy.  Died  on  8th  day.  Autopsy:  Peritonitis, 
.streptococcus  septicemia,  broncho-pneumonia. 

137.  Dec.  7,  1910.  E.  S.  173186.  Male— 54.  Typical  history  of  duodenal 
ulcer.  Op.  E.  A.  C. — Gall  bladder,  which  was  full  of  stones  and  ad- 
herent to  duodenal  ulcer,  removed.  Ulcer,  which  was  posterior,  dis- 
sected up  and  infolded.  Post,  gastroenterostomy.  Died  on  5th  day. 
Sepsis. 

138.  Mar.  7,  1913.  E.  S.  187959.  Female— 26.  Had  all  the  classical  second- 
ary complications  of  gastric  ulcer:  perforation,  hemorrhage,  and  ob- 
struction. Repeatedly  seen  in  medical  wards  from  Mar.  7  to  Apr.  10, 
and  her  condition  considered  too  feeble  for  operation.  Op.  E.  A.  C. — 
Apr.  10,  1913 — A  small  ulcer  of  duodenum  and  a  large  penetrating 
ulcer  of  lesser  curvature  adherent  to  pancreas.  Partial  gastrectimy, 
with  the  aid  of  Dr.  C.  A.  Porter,  whom  I  called  in  to  help  me.  Death 
next  morning.    Shock. 

139.  Mar.  29,  1913.  E.  S.  188207.  Male— 50.  Typical  ulcer  symptoms  for 
15  yrs.    Came  to  hospital  as  last  resort.    A  poor  risk.    Op.  E.  A.  C. — 

154 


Multiple  duodenal  ulcers.  Multiple  right-sided  adhesions;  adherent 
appendix.  Appendectomy;  post,  gastroenterostomy.  Died  on  11th  day. 
Pulmonary  emboli. 

140.  June  12,  1912.  E.  S.  183136.  Female— 48.  Typical  severe  symptoms  of 
chr.  gastric  ulcer.  Had  been  operated  on  by  another  surgeon  18  months 
previously— gastroenterostomy.  Op.  E.  A.  C— Large  posterior  ulcer, 
adherent  to  pancreas.  The  old  gastroenterostomy  was  patent,  but  was 
below  the  ulcer.  Partial  gastrectomy  seemed  the  only  thing  likely  to 
relieve  her,  and  was  attempted  in  spite  of  her  feeble  condition.  Death 
within  24  hrs.  from  shock. 

141.  Dec.  30,  1912.  E.  S.  186816.  Male— 56.  Typical  advanced  symptoms 
of  duodenal  ulcer.  Op.  E.  A.  C. — A  sub-acute  perforation  of  an  en- 
circling duodenal  ulcer.  Gastroenterostomy.  A  finger  of  omentum  was 
adherent  to  the  perforation.  Instead  of  removing  this  bit  of  omentum 
and  then  infolding,  I  infolded  over  the  fat.  I  attribute  the  leakage 
which  occurred  to  this.    Death  on  7th  day. 

Greater  skill  and  better  judgment  undoubtedly  might  have  saved 
a  few  of  these  cases,  but  where  is  such  skill  and  judgment  to  be 
found?  Can  the  Trustees  of  the  Massachusetts  General  Hospital 
produce  evidence  of  such  skill  and  judgment  from  the  consecutive 
records  of  any  other  surgeon?  Do  the  abstracts  of  the  fatal  cases 
in  their  Reports  point  to  it?^ 

If  not,  I  claim  the  appointment  as  Chief  of  Staff  under  the  same 
ruling  that  caused  my  resignation: 

"Resolved,  that  in  making  appointments  the  Trustees  will  con- 
sider the  fitness  of  the  applicant  for  the  special  services  which  he 
will  be  called  on  to  perform,  and  will  seek  to  secure  the  best  service 
available,  without  being  bound  by  any  custom  of  promotion  by 
seniority." 

And  even  if  such  superiority  can  be  shown  in  the  record  of 
another,  I  claim  the  right  to  reappointment  under  him,  so  that  I 
may  try  to  serve  the  hospital  better  than  he  does.  I  only  covet 
the  position  of  Chief,  in  order  to  be  forced  out  of  it  by  a  better  man. 

The  Truth  is  that  no  Boston  Board  of  Trustees  could  give  me 
a  Surgical  appointment  without  displacing  one  of  my  friends.  Even 
if  I  were  put  in  to  fill  a  vacancy,  the  man  who  was  "in  line"  for 
that  vacancy  would  feel  injured, —  so  deep-rooted  is  our  Seniority 
System.  Even  if  a  single  group  of  cases  should  be  assigned  to  me, 
some  one  would  feel  robbed  of  his  "material."  And  as  for  me,  I  do 
not  wish  to  replace  any  of  my  friends,  unless  it  is  very  clear  that 
I  can  and  will  do  the  work  more  efficiently. 

However,  I  am  only  too  well  aware  that  to  these  Trustees  honest 
aggression  is  far  more  heinous  a  crime  than  nepotism  or  humbug, 
so  that  I  must  prepare  to  make  my  own  way  in  spite  of  their  dis- 
api^roval.  It  is  clear  from  the  financial  report  just  presented  that 
I  must  reorganize  my  work,  invite  a  consulting  staff,  obtain  finan- 
cial backing,  and  actually  drive  the  Massachusetts  General  out  of 
Business  and  back  into  Charity.  How  this  may  be  done  will  be 
developed  in  Part  III. 

^  Trustees  may  be  sure  that  their  hospitals  are  badly  organized,  if  the  Chiefs  of  Staff  do 
not  have  a  higher  mortality  from  their  operations  than  their  Juniors  do. 

165 


BIBLIOGRAPHY 

I  publish  this  Bibliography  as  an  evidence  that,  even  if  I  did 
lose  these  cases,  I  studied  and  recorded  the  "material"  which  I  had 
the  "privilege  of  using."  Many  of  the  cases  which  died  will  be 
found  reported  and  analyzed  in  these  papers.  Can  the  Trustees 
show  that  any  other  surgeon  on  their  staff  made  better  use  of  his 
"material"?  What  is  the  use  of  studying  and  writing  and  effort 
to  add  to  the  world's  knowledge,  if  the  mere  operator  is  to  be  pro- 
moted? I  could  be  satisfied  if  his  End  Results  were  better.  But 
unless  they  were,  the  scholar,  poor  as  he  may  be,  should  take 
precedence  of  the  operator.  Is  surgery  a  science  or  a  technique? 
Is  the  object  relief  or  display? 

Then  take  my  Papers  on  the  Shoulder  Joint.  I  do  not  boast 
when  I  state  that  these  have  been  accepted  in  Surgical  Literature. 
I  have  received  credit  from  foreign  writers,  from  the  text-books,  and 
from  practically  every  writer  on  the  "shoulder."  But  the  Massa- 
chusetts General,  the  hospital  for  whose  cases  I  did  the  work,  has 
given  me  no  credit  for  it,  in  spite  of  the  fact  that  every  case  I  treated 
was  benefited.  Was  I  asked  to  continue  to  treat  the  shoulder  cases  ? 
Are  such  cases  ever  referred  to  me  now  by  the  Hospital?  Or  are 
these  cases  simply  neglected  in  the  hurry  of  the  Out-Patient  work? 
Who  cares  whether  they  are  relieved?  Are  the  Trustees,  the  Chiefs 
of  Staff,  or  any  one  else  held  accountable  for  them?  Have  my  results 
ever  been  improved  upon? 

1.  Experiments  on  the  Application  of  the  Roentgen  Rays  to  the  Study  of 

Anatomy.    The  Journal  of  Experimental  Medicine,  Vol.  Ill,  No.  3, 
1898. 

2.  A  Study  of  the  X-ray  Plates  of  One  Hundred  and  Forty  Cases  of 

Fracture  of  the  Lower  End  of  the  Radius.    Boston  Medical  and  Sur- 
gical Journal,  Vol.  CXLIII,  No.  13,  pp.  305-308,  Sept.  27,  1900. 

3.  A  Study  of  the  Cases  of  Accidental  X-ray  Burns  Hitherto  Recorded. 

Philadelphia  Medical  Journal,  March  8,  1902. 

4.  The  Use  of  the  X-ray  in  Surgery.     Johns  Hopkins  Hospital  Bulletin, 

Vol.  XIV,  No.  146,  May,  1903. 

6.  The  Formation  of  Loose  Cartilages  in  the  Knee  Joint.  Boston  Medical 
and  Suryical  Journal,  Vol.  CXLIX,  No.  16,  p.  427,  Oct.  15,  1903. 

fl.  Report  of  a  Case  of  Bone  Cyst  of  a  Digital  Phalanx.  Boston  Medical 
and  Surgical  Journal,  Vol.  CL,  No.  8,  pp.  211-212,  Feb.  25,  1904. 

T.  A  R4sum6  of  the  Results  of  Dr.  F.  B.  Harrington's  Service  at  the 
Massachusetts  General  Hospital,  from  June  1  to  Oct.  1,  1900,  as 
Seen  in  the  Following  June  or  Later.  Boston  Medical  and  Surgical 
Journal,  Vol.  CXLVI,  No.  20,  May  15,  1902.  (A  similar  study  was 
also  published  for  the  two  following  years.)  Boston  Medical  and 
Surgical  Journal,  Vol.  CL,  No.  23,  June  9,  1904. 

8.  Some   Points   on   the   Diagnosis   and   Treatment   of   Certain   Neglected 

Minor  Surgical  Lesions.    Boston  Medical  and  Surgical  Journal,  Vol. 
CL,  No.  14,  pp.  371-374,  April  7,  1904. 

9.  A  Method  of  Rhinoplasty  Illustrated  by  Plastic  Operation  for  Rodent 

Ulcer  on  the  Face.    Boston  Medical  and  Surgical  Journal,  Vol.  CLII, 
No.  10,  pp.  276-278,  March  9,  1905. 

156 


10.  The  Diagnosis  and  Treatment  of  Fracture  of  the  Carpal  Scaphoid  and 

Dislocation  of  the  Semilunar  Bone.  Annals  of  Surgery,  March  and 
June,  1905. 

11.  Observations  upon  the  Actual  Results  of  Cerebral  Surgery  at  the  Massa- 

chusetts General  Hospital.  Boston  Medical  and  Surgical  Journal, 
Vol.  CLIII,  No.  3,  pp.  74-76,  July  20,  1905. 

12.  On  Stiff  and  Painful   Shoulders.     The   Anatomy  of  the  Subdeltoid  or 

Subacromial  Bursa  and  Its  Clinical  Importance.  Subdeltoid  Bursitis. 
Boston  Medical  and  Surgical  Journal,  Vol.  CLIV,  No.  22,  pp.  613- 
620,  May  31,  1906. 

13.  A   Case   of   Recurrent   Spontaneous   Gangrene   of   the   Index   Finger; 

Successive  Amputations  of  the  Phalanges;  Abatement  of  the  Process 
after  Excision  of  a  Portion  of  the  Radial  Nerve  and  Stretching  of 
the  Median.  Boston  Medical  and  Surgical  Journal,  Vol.  CLV,  No.  2, 
pp.  33-36,  July  12,  1906. 

14.  On  the  Bier  Treatment  of  Infectious  and  Septic  Wounds  of  the  Ex- 

tremities. Boston  Medical  and  Surgical  Journal,  Vol.  CLV,  No.  16, 
pp.  434-435,  Oct.  18,  1906. 

15.  Case  of  Bullet  Wound  of  the  Brain;  Successful  Removal  of  the  Bullet. 

Boston  Medical  and  Surgical  Journal,  Vol.  CLVIII,  No.  7,  pp.  228- 
229,  Feb.  13,  1908. 

16.  Observations  on  Six  Cases  of  Acute  Perforating  Ulcer  of  the  Duodenum. 

Boston  Medical  and  Surgical  Journal,  Vol.  CLVIII,  No.  7,  pp.  217- 
219,  Feb.  13,  1908. 

17.  Remarks  upon  Intussusception,  with  a  Suggestion  for  a  New  Method 

of  Operation  upon  Cases  in  Which  Reduction  Is  Not  Possible,  Boston 
Medical  and  Surgical  Journal,  Vol.  CLVIII,  No.  14,  pp.  438-446, 
April  2,  1908. 

18.  Chronic  Obstruction  of  the  Duodenum  by  the  Root  of  the  Mesentery. 

Boston  Medical  and  Surgical  Journal,  Vol.  CLVIII,  No.  16,  pp.  503- 
610,  April  16,  1908. 

19.  A  Case  of  Intra- Vesical  Cyst  of  the  Ureter;  Dilatation  of  Ureter  with 

Very  Slight  Dilatation  of  the  Renal  Pelvis,  and  Containing  Twenty- 
eight  Movable  Calculi;  Bacteriuria;  Alkalinuria;  Phosphaturia. 
Boston  Medical  and  Surgical  Journal,  Vol.  CLVIII,  No.  22,  pp.  828- 
831,  May  28,  1908. 

20.  Bursitis  Subacromialis,  or  Periarthritis  of  the  Shoulder  Joint.    (Sub- 

Deltoid  Bursitis.)  Records  of  the  Massachusetts  Medical  Society, 
June  9,  1908.  Boston  Medical  and  Surgical  Journal,  Oct.  22,  29; 
Nov.  5,  12,  19,  26;  Dec.  3,  1908. 

21.  Bone  Transference.    Report  of  a  Case  after  the  Method  of  Huntington. 

Annals  of  Surgery,  June,  1909. 

22.  The  Diagnosis  of  Ulcer  of  the  Duodenum.    Proceedings  of  the  Massa- 

chusetts Medical  Society,  June  15,  1909.  Boston  Medical  and  Surgical 
Journal,  Vol.  CLXI,  No.  22,  Nov.  18,  1909;  Vol.  CLXI,  No.  23,  Dec.  2, 
1909;  Vol.  CLXI,  No.  25,  Dec.  9,  1909. 

23.  The  Use  of  the  X-ray  and  Radium  in  Surgery.    Keene's  Surgery,  1909 

and  1913. 

24.  On  the  Surgical  Significance  of  Pus,  Blood,  and  Bacteria  in  the  Urine. 

Boston  Medical  and  Surgical  Journal,  Vol.  CLXI,  No.  6,  pp.  177-183, 
August  5,  1909. 

25.  On  the  Importance  of  Distinguishing  Simple  Round  Ulcers  of  the  Duo- 

denum from  Those  Ulcers  Which  Involve  the  Pylorus  or  Are  Above 
It.  Boston  Medical  and  Surgical  Journal,  Vol.  CLXI,  Nos.  10,  11,  12, 
Sept.  2,  9,  16,  1909. 

167 


26.  Case   of   Mesenteric  Thrombosis;   Resection  of  Intestine;   End-to-End 

Anastomosis.  Recovery.  Boston  Medical  and  Surgical  Journal,  Vol. 
CLXII,  No.  11,  pp.  355-357,  Marcli  17,  1910. 

27.  Depressed  Fracture  of  the  Malar  Bone.    A  Simple  Method  of  Reduc- 

tion. Boston  Medical  and  Surgical  Journal,  Vol.  CLXII,  No.  16, 
p.  532,  April  21,  1910. 

28.  Complete  Rupture  of  the  Supraspinatus  Tendon.    Operative  Treatment 

with  Report  of  Two  Successful  Cases.  Boston  Medical  and  Surgical 
Journal,  Vol.  CLXIV,  No.  20,  pp.  708-710,  May  18,  1911. 

29.  Duodenal   Ulcer.    Boston  Medical  and  Surgical  Journal,  Vol.   CLXV, 

No.  2,  pp.  64-59,  June  13,  1911. 

30.  "On  Stiff  and  Painful  Shoulders,"  as  explained  by  Subacromial  Bursitis 

and  Partial  Rupture  of  the  Tendon  of  the  Supraspinatus.  Boston 
Medical  and  Surgical  Journal,  Vol.  CLXV,  No.  4,  pp.  115-120,  July  27, 
1911. 

31.  Diagnosis  of  Diseases  of  the  Stomach  and   Intestines  by  the  X-ray. 

Boston  Medical  and  Surgical  Journal,  Vol.  CLXVI,  No.  5,  pp.  155- 
159,  Feb.  1,  1912. 

32.  Abduction  of  the  Shoulder.    An  Interesting  Observation  in  Connection 

with  Subacromial  Bursitis  and  Rupture  of  the  Tendon  of  the  Supra- 
spinatus. Boston  Medical  and  Surgical  Journal,  Vol.  CLXVI,  No.  24, 
pp.  890-891,  June  13,  1912. 
83.  Discussion  of  paper  by  S.  W.  Goddard,  M.D.:  Surgical  Treatment  of 
Pyloric  Stenosis,  with  Report  of  Cases.  Boston  Medical  and  Surgical 
Journal,  Vol.  CLXV,  No.  13,  pp.  482^83,  Sept.  28,  1911. 

34.  Our  Little  Balloons.     Some  Observations  on  Gas  and  Ptosis.    Boston 

Medical  and  Surgical  Journal,  Vol.  CLXIX,  No.  15,  pp.  540-542, 
Oct.  9,  1913. 

35.  Observations   on   a  Series  of  Ninety-eight  Consecutive  Operations   for 

Chronic  Appendicitis.  Medical  Communications  of  the  Massachusetts 
Medical  Society,  Vol.  XXIV,  1913;  Boston  Medical  and  Surgical 
Journal,  Vol.  CLXIX,  No.  14,  Oct.  2,  1913. 

36.  The  Prognosis  of  Sarcoma  of  the  Testicle.    Boston  Medical  and  Surgical 

Journal,  Vol.  CLXX,  No.  8,  pp.  267-269,  Feb.  19,  1914. 

37.  Money  Spent  on  Hospitals  Is  for  Cure  of  Patients.    Follow-up  System 

the  Only  Way  to  Determine  Value  of  Institution's  Services  —  Ac- 
counts Must  Include  Death  and  Disability,  Which  Are  Wasted  Effort. 
The  Modern  Hospital,  Vol.  II,  No.  2,  Feb.,  1914. 

38.  The  Product  of  a  Hospital.    Surgery,  Gynecology,  and  Obstetrics,  pp. 

491-496,  April,  1914. 

39.  A  Study  in  Hospital  Efficiency.    As  Demonstrated  by  the  Case  Report 

of  tiie  First  Two  Years  of  a  Private  Hospital.    May  10,  1914. 

40.  A  Study  in  Hospital  EfiBciency.    As  Demonstrated  by  the  Case  Report 

of  the  Second  Two  Years  of  a  Private  Hospital.    Oct.  19,  1915. 

41.  Report  of  Committee  on  Hospital  Standardization.    (Report  of  Com- 

mittee of  Clinical  Congress  of  Surgeons.)  Surgery,  Gynecology,  and 
Obstetrics,  Jan.,  1914,  and  Jan.,  1916. 

42.  The   Dividing   Line    between    Medical   Charity    and   Medical   Business. 

Medical  Record,  May  13,  1916. 

43.  A  Wise  Preliminary  to  the  Adoption  of  Any  Compulsory  Health  In- 

surance Act.  Boston  Medical  and  Surgical  Journal,  Vol.  CLXXVI, 
No.  12,  pp.  435-438,  March  22,  1917. 

44.  Uniformity  in  Hospital  Morbidity  Reports.    Boston  Medical  and  Sur- 

gical Journal,  Vol.  CLXXVI  I,  No.  9,  pp.  279-283,  August  30,  1917. 

158 


Have  these  papers  any  financial  value?  I  certainly  could  find 
no  buyer  for  the  copyrights,  but  in  my  opinion  they  are  of  far  more 
value  to  humanity  than  all  the  money  I  have  ever  made  by  treating 
my  individual  patients.  By  the  shoulder  work  alone,  countless 
patients  have  been  and  will  be  helped  in  the  hands  of  other  doctors. 
Now  in  your  opinion  my  writings  may  not  be  worth  the  paper  they 
are  printed  on,  but  you  cannot  say  the  same  of  the  writings  of  really 
original  surgical  observers  and  students.  Even  these  men,  after 
they  have  gained  reputations,  not  only  are  not  directly  paid  for  their 
original  work,  but  they  have  to  pay  large  amounts  for  the  prepara- 
tion and  illustration  of  their  articles.  And  their  enthusiasm  for  their 
work  is  so  great,  that  they  are  even  willing  to  humbug  the  rich,  to 
get  money  to  pay  for  their  all-absorbing  passion  of  making  the  most 
of  their  brains  to  benefit  mankind. 

No,  there  is  no  market  for  plain,  truth-telling  clinical  articles. 
They  are  not  worth  a  cent,  and  most  medical  publications  even 
demand  that  the  author  pay  for  the  illustrations.  The  natural  con- 
sequence is  a  tendency  to  write  for  advertising  purposes.  Nine- 
tenths  of  our  medical  and  surgical  literature  is  published  for  this 
purpose  alone,  and  the  best  of  it  is  but  a  mixture  of  advertisement 
and  true  science.  It  is  the  accepted  usage  of  the  profession  to  adver- 
tise in  this  way, —  a  man  is  not  expected  to  report  his  errors  and 
failures.  Naturally,  as  his  living  depends  on  it,  he  keeps  his  best 
foot  forward. 

Why  did  I  write  these  articles.?  As  I  look  back  to  analyze  my 
intentions,  so  that  I  may  see  those  of  others,  I  find  the  following 
reasons: 

1.  Advertisement  for  personal  business. 

2.  Hope  of  recognition  of  ability  by  my  own  hospital,  the  Massa- 
chusetts General,  by  my  colleagues  and  friends,  by  my  distant 
readers,  and  by  the  rising  generation. 

3.  A  real  desire  to  use  the  best  that  lies  in  me  to  do  my  bit  for 
humanity,  recognition  or  no  recognition. 

I  always  had  all  three  in  mind,  and  I  believe  most  men  who  write 
have  also.  The  proportion  varies  somewhat,  and  the  true  value  and 
the  financial  value  are  usually  in  inverse  proportion.  I  believe  that 
in  my  own  case  the  desire  to  be  recognized  by  my  own  hospital 
weighed  the  strongest.  I  thought  that  if  I  could  do  well,  I  should 
receive  recognition  and  be  promoted.  I  imagined  that  the  Trustees 
of  the  hospital  wanted  such  work  done,  and  that  if  I  kept  at  it  and 
took  good  care  of  all  my  cases,  I  should  get  on  in  time.  I  knew,  of 
course,  that  every  hour  I  spent  on  such  work  instead  of  on  technical 
experience  and  personal  attention  to  patients,  put  me  behind  in 
private  practice ;  but  I  hoped  that  some  one  was  watching  my  efforts, 
and  that  the  time  would  come  when  the  Trustees  would  keep  track 
of  results  and  discover  that  study  might  really  fit  a  surgeon  to  benefit 
their  patients.  I  kept  thinking  that  if  the  Trustees  should  advertise 
me  by  promotion  for  merit,  there  would  be  no  need  of  diluting  mv 

159 


articles  with  personal  advertisement!  If  I  had  only  been  sure  of 
promotion  by  merit  for  relieving  my  patients,  I  could  have  spent 
more  and  more  time  in  studying  how  to  relieve  them!  But  no,  I  find 
that  they  expected  me  to  go  on  accumulating  a  good  private  practice, 
in  order  to  make  a  good  living  and  a  reputation.  They  would  have 
pretended  to  be  grateful  when  I  had  continued  to  hold  my  appoint- 
ment some  years  after  my  actual  usefulness  had  ceased,  and  had 
allowed  my  reputation  to  cover  their  delinquencies. 

Would  it  not  be  possible  to  use  the  ambition  of  young  men  openly 
and  fairly  ?  None  of  us  desires  to  spend  energy  in  study  and  writing, 
unless  thereby  we  become  better  surgeons.  If  technique  and  repu- 
tation are  the  things  to  acquire,  to  have  better  success  with  our 
patients,  what  is  the  use  of  wasting  time  reading  and  writing,  once 
we  have  got  our  Degrees?  If  Trustees  had  an  End  Result  System, 
they  could  tell  whether  to  promote  scholars  or  operators,  and  both 
scholars  and  operators  might  know  their  own  deficiencies  and  be  able 
to  proportion  their  work. 

Some  of  these  papers  of  mine  have  received  recognition, — must 
I  therefore  be  classed  as  a  scholar,  no  matter  how  well  my  cases  do? 
As  a  matter  of  fact,  my  "practical"  colleagues  might  have  written 
better  papers,  if  they  had  been  obliged  to,  to  keep  their  positions. 
The  whole  realm  of  surgery  is  at  present  so  permeated  with  humbug, 
that  any  one  who  will  tell  the  plain,  unvarnished  truth  about  a  series 
of  cases,  will  find  that  he  is  writing  an  epoch-making  paper !  Can- 
not Trustees  see  that  a  true  End  Result  Report  of  their  hospital 
cases  will  be  the  first  tangible  directory  to  competent  doctors, 
whether  the  hospital  is  associated  with  a  university  or  not? 

But  as  for  the  money  value  of  my  papers, —  I  am  determined  to 
find  this  out  by  selling  this  Report.  Let  every  reader  send  me  what 
he  considers  the  value  of  this  Report  to  him.  If  I  get  back  the 
money  it  has  cost  me,  I  shall  write  another  one,  but  I  do  not  care 
to  write  another  for  mere  advertising.  Whatever  money  comes  in 
for  this  Report,  will  be  returned  in  full  value  in  the  next  Report. 
If  this  Report  is  not  paid  for,  I  shall  know  that  my  duty  is  done  as 
far  as  writing  papers  goes.  Writing  papers  is  the  hardest  part  of 
modern  surgery ! 


160 


PART  III 
THE   NEW   ORGANIZATION 

AN  ILLUSTRATION  OF  HOW  A  GROUP  OF  EARNEST  MEN 

MAY  COMPETE  WITH  THE   CLIQUES  WHO   DOxMINATE 

THE  CHARITABLE  HOSPITALS  IN  ANY  CITY 

PAGE 

The  New  Position  of  the  General  Practitioner  .          .  163 

Feb— Splitting          ........  164 

The  Business  Value  of  a  Consultant   ....  165 

Our  New  Finance  ........  166 

Institutions  from  Which  I  Should  Be  Glad  to  Accept 

Proffered  Loans      .......  169 

How  Can  I  Obtain  a  Staff  of  Specialists?   .         .         .  169 

Duties  of  the  Consulting  Staff   .....  172 

A  Staff  Which  Is  Sought — Not  One  Which  Is  Seeking,  172 

Cutting  Prices  or  Raising  Prices?         .         .         .         .  174 

How  May  the  Young  Surgeon  Make  His  Start  under 

the  End  Result  System?         .....  175 

Advertisement          ........  178 

Last  Word       .........  179 


162 


PART  III 

THE   NEW    ORGANIZATION 

AN  ILLUSTRATION  OF  HOW  A  GROUP  OF  EARNEST 

MEN  MAY  COMPETE  WITH  THE  CLIQUES  WHO 

DOMINATE  THE  CHARITABLE  HOSPITALS 

IN  ANY  CITY^ 


The  New  Position  of  the  General  Practitioner   ' 

The  day  of  the  general  practitioner  is  passing,  it  has  almost 
passed  in  thickly  settled  regions ;  but  the  day  of  the  isolated  special- 
ist has  also  begun  to  pass.  Economic  conditions  do  not  permit  the 
average  person  to  employ  the  latter.  Combinations  of  experts  will 
to  a  great  extent  take  the  place  of  both,  except  in  the  unusual  in- 
stances when  the  individual  can  maintain  himself  by  his  actual 
superiority  in  his  own  field. 

We  believe  that  there  is  today  a  demand  for  institutions  repre- 
senting combinations  of  specialists,  to  which  the  patient  may  pay 
one  moderate  fee  and  in  return  receive  the  benefit  of  the  advice  of 
one  or  all  of  the  experts  of  the  institution. 

We  believe  that  the  modern  role  of  the  general  practitioner  will 
be  as  confidential  adviser  to  the  patient,  to  help  to  obtain  from  such 
institutions  the  diagnosis  and  expert  treatment  necessary,  and  to 
interpret  and  weigh  the  advice  received. 

This  will  lead  to  a  reversal  of  the  present  relations.  Now,  the 
specialist  sees  few  cases,  and  gets  overpaid  for  each ;  the  practitioner 
sees  many  cases,  and  gets  underpaid  for  each.  The  time  must  come 
when  the  former  cares  for  many  cases  at  small  fees,  and  the  prac- 
titioner for  fewer  cases  at  relatively  large  fees.  Logically,  this  state 
of  affairs  should  come  about,  because  the  expert  must  necessarily 
acquire  and  retain  facility  by  doing  what  he  does  many  times;  and, 
on  the  other  hand,  the  general  practitioner  will  have  to  take  much 
time  with  each  individual,  and  will  have  to  have  a  wide  knowledge, 
so  as  to  understand  to  a  certain  degree  all  branches  of  medicine, 
and  what  results  are  to  be  expected. 

If  an  institution  subdivides  its  work  among  many  individuals, 
each,  like  the  specialized  laborer  in  industry,  will  do  the  same  thing 
again  and  again,  and  become  more  and  more  skillful.    The  patient 

'  The  same  method  may  be  used  in  competition  with  "  Fee-Splitters." 

163 


is  like  the  buyer  of  a  boot  made  by  many  workers.  The  doctor  or 
general  practitioner  is  the  retailer.  He  fits  the  boot  to  the  needs, 
taste,  and  pocketbook  of  the  individual  customer. 

The  doctor  of  today  cannot  give  expert  treatment  any  more  than 
the  retail  shoe  dealer  can  make  all  parts  of  the  boot.  The  doctor 
must  hold  his  custom  by  fitting  the  individual  with  satisfactory  boots. 
In  the  future,  the  Public  will  realize  that  what  they  want  from  the 
doctor  is  advice,  as  from  a  man  and  a  friend,  as  to  how  to  obtain 
(not  to  expect  him  to  give)  adequate  diagnosis  and  treatment.  They 
will  realize  the  impossibility  of  his  being  able  to  diagnose  and  treat 
unusual  conditions  effectively.  Their  chief  need  for  him  will  be  as 
adviser  and  sympathetic  friend,  and  he  will  be  paid  as  such,  not 
as  a  purveyor  of  makeshift  and  ineffective  treatment.  They  will 
rely  on  him  more  because  he  does  not  give  treatment,  than  because 
"he  does  the  best  he  can." 

But  the  sine  qua  non  of  this  honored  relationship  must  be  the 
establishment  of  institutions  where  the  services  of  experts  can  be 
obtained  when  necessary,  at  reasonable  prices.  The  Massachusetts 
General  Hospital  has  recognized  this  fact  in  the  establishment  of 
their  "pay  clinic"  for  persons  of  moderate  means. 

It  is  the  intention  of  this  hospital  to  put  another  competitive 
combination  of  specialists  at  the  disposal  of  practitioners  who  would 
like  to  hold  this  relationship  to  their  patients,  and  of  patients  who 
want  to  establish  this  relationship  to  their  physicians.  We  plan  to 
sell  standard  goods ;  we  are  not  a  Charity  which  gives  away  un- 
standardized  "seconds,"  nor  do  we  set  up  as  experts,  like  the  most 
fashionable  "make  to  order"  tailors. 

Fee— Splitting 

The  much  condemned  practice  of  fee-splitting  is  the  result 
of  such  large  fees  being  charged  for  operations  or  other  special 
forms  of  treatment,  that  the  temptation  to  split  them  naturally 
arises.  Fee-splitting  means  that  a  physician  urges  his  patient 
to  go  to  a  certain  surgeon.  The  patient  pays  a  large  fee  to  the 
surgeon,  and  the  surgeon,  without  the  knowledge  of  the  patient, 
rebates  a  part  of  it  to  the  physician  for  having  brought  him  the  case. 
To  a  business  man,  accustomed  to  the  usual  methods  of  giving  a 
commission  to  the  person  who  brings  a  customer,  this  practice  does 
not  seem  so  very  shocking.  It  is  the  customer's  lookout  to  see  that 
he  gets  a  fair  bargain.  But  in  the  case  of  surgery,  the  fact  that  the 
customer  is  not  qualified  to  protect  himself  (for  he  has  no  means 
of  judging  whether  the  services  received  are  valuable)  changes 
the  question  entirely.  The  patient  must  put  liis  trust  in  his  physi- 
cian, and  if  that  physician  betrays  him,  a  criminal  act  is  committed. 
In  this  community  I  sincerely  believe  that  such  acts  are  very  rare, 
but  we  are  not  guiltless  of  the  primary  crime  of  overcharging  for 
simple  operations  for  which  the  laity  shows  a  readiness  to  pay 
ridiculously  high  prices.    No  wonder  the  practitioner  is  tempted  to 

164 


get  his  rake-off,  when  he  sees  some  surgeon  receive  a  large  cheek 
for  an  hour's  simple  work,  while  he  himself  has  done  the  real  work 
and  taken  the  real  responsibility,  by  convincing  the  patient  that  an 
operation  was  necessary  or  wise. 

It  is  our  intention  to  Split  Fees  among  ourselves,  and  to  make 
the  P'ees  thus  split  so  small,  that  the  patient  may  have  something 
left  with  which  to  pay  his  friend  the  practitioner,  enough  to  recom- 
pense him  for  the  time  and  trouble  he  has  taken.  We  shall  try  to 
teach  each  patient  what  responsibility  his  doctor  has  taken  in  advis- 
ing the  operation.  We  shall  urge  each  patient  to  ask  his  doctor  to 
attend  the  operation,  so  that  he  may  be  convinced  of  the  pathologic 
findings,  and  that  he  may  know  with  what  care  his  case  is  conducted. 
Few  patients  realize  how  important  for  their  after-care  it  is,  to  have 
their  doctor  see  the  actual  pathologic  conditions  demonstrated  at  the 
operation.  The  patient  should  pay  him  for  his  time  and  trouble, 
for  the  Fees  we  ask  are  too  small  to  stand  Splitting  behind  the 
patient's  back. 

The  Business  Value  of  a  Consultant 

If  a  person  can  understand  the  business  value  to  a  practitioner 
of  a  surgeon  who  will  split  fees  with  him,  it  will  not  be  difficult  for 
him  to  understand  the  reverse  position  of  the  value  to  a  surgeon  of 
a  consulting  general  practitioner. 

A  surgeon's  income  largely  depends  on  his  popularity  with  the 
general  practitioners  and  medical  consultants,  for  they  can  "steer" 
the  patient  into  his  hands.  It  is,  therefore,  for  his  interest  to  do  the 
following  things,  which  are  well  recognized  as  legitimate  methods 
of  increasing  his  clientele  among  the  practitioners: 

1.  To  make  himself  personally  agreeable  to  them. 

2.  To  back  them  up,  when  their  cases  go  wrong. 

3.  To  pay  particular  attention  to  those  of  their  cases  that  enter 

the  Charitable  Hospitals. 

4.  To  operate  on  or  attend  gratis  the  members  of  their  families. 

5.  To  insist  that  the  practitioner's  bill  is  paid  before  their  own. 

6.  To  take  the  conservative  side  on  public  questions  pertaining 

to  reforms  of  medical  practice. 

If  a  new  consultant  brought  me  100  new  cases  next  year,  and 
these  cases  paid  me  only  the  "Hospital  Fee"  and  no  "Professional 
Fee,"  my  hospital  would  be  a  financial  success,  as  shown  on 
page  119.  Ten  consultants  might  send  me  ten  cases  each,  or  100 
might  send  me  one  each.  This  would  mean  10,000  more  dollars  for 
my  receipts,  without  any  great  increase  in  my  expenditure.  If  these 
cases  should  each  pay  also  $100  Professional  Fee,  I  should  have 
$10,000  more  to  spend  on  my  colleagues  and  assistants.  This  would 
put  my  undertaking  on  a  solid  basis.  One  fashionable  Back  Bay 
practitioner  could  do  this  for  me,  if  he  had  the  courage  to  take  his 
share  in  the  publicity. 

165 


Two  and  two  make  four.  Consider  the  financial  value  to  a 
surgeon  of  friendship  and  cordial  relations  with  some  prominent 
Back  Bay  consultant  whose  practice  is  among  the  rich  and  fashion- 
able!  Such  "Entente  Cordiale"  relations  seriously  interfere  with 
Hospital  Efficiency.     If  you  are  rich,  you  probably  do  not  see  why. 

Our  New  Finance 
(See  also  page  122,  Part  II) 

The  hospital  is  already  equipped  to  do  business  and  to  take  care 
of  more  patients  than  come  to  us,  but  in  course  of  time  we  shall 
need  more  space  and  more  equipment  of  various  kinds. 

For  instance,  it  is  now  clear  to  me  that  $10,000  invested  in  a 
better  X-ray  plant  and  an  elevator  would  bring  more  than  a  10  per 
cent  increase  in  new  business  and  in  greater  facility  in  conducting 
that  which  we  already  have.  I  shall,  therefore,  put  in  these  improve- 
ments by  calling  in  $10,000  of  the  proffered  loans,  of  which  there 
will  always  be  the  following  list  in  the  order  in  which  they  will  be 
called  in: 

1.  Employees'  loans  (to  an  amount  not  over  $10,000  each)  at 
10  per  cent  interest.  Of  this  10  per  cent,  5  per  cent  will  be  paid 
from  the  Hospital  Fees  and  6  per  cent  from  the  Professional  Fees. 

2.  Loans  at  5  per  cent  by  members  of  the  Staff  for  any  appa- 
ratus or  equipment  they  individually  especially  desire.  (Provided 
they  do  not  call  the  loan  within  five  years.) 

3.  Loans  by  former  patients  at  5  per  cent. 

4.  Loans  by  members  of  the  medical  profession  at  5  per  cent. 

5.  Loans  by  the  laity  in  general  at  5  per  cent. 

Now,  if  there  is  a  good  subscription  list  of  these  loans,  we  can 
enlarge  the  plant  each  year  in  proportion  to  the  net  earnings  of  the 
previous  year. 

As  my  personal  property  is  worth  $50,000,^  and  all  loans  will 
be  secured  by  my  note  until  the  Institution  is  incorporated,  no 
stockholder  would  run  any  risks  except  from  my  personal  failure. 
Also,  since  I  can  make  no  income  until  the  interest  on  the  stock  is 
paid,  the  stockholders'  annual  interest  is  guaranteed. 

The  result  will  be  the  absorption  of  all  the  loans  by  the  em- 
ployees, so  that  when  the  hospital  is  incorporated,  it  will  be  by  the 
employees  and  myself.  All  the  other  persons  who  have  proffered 
loans  will  merely  be  underwriters  of  the  End  Result  Idea  and  of 
my  personal  ability  to  put  it  through.  But  an  imposing  list  of  under- 
writers, with  the  proffered  loans  running  into  millions,  when  pub- 
lished in  our  next  Report,  will  make  the  Trustees  of  Hospitals  and 
Corporations  of  Universities  begin  to  take  interest  in  the  idea. 

'  Even  if  this  were  $500,000,  it  should  not  exclude  me  from  competition  in  a  Charitable 
Ho8pita.l  or  irith  Charitable  Ho-spilals. 

166 


Details  of  Plan 

All  loans  and  the  interest  thereon  will  be  secured  by  E.  A.  C.'s 
note  until  the  total  investment  in  excess  of  the  present  plant  reaches 
$100,000,  when  the  Hospital  will  be  incorporated  by  the  stockhold- 
ers, with  the  following  statements  in  the  articles  of  incorporation: 

1.  The  Hospital  shall  be  known  as  The  End  Result  Hospital, 

2.  An  End  Result  Report  of  all  the  cases  who  enter  the  Hospital 
must  be  published  annually  and  sold  at  $1  apiece  to  any  subscriber. 

3.  The  rates  of  the  Hospital  and  Professional  Fees  must  never 
be  increased,  so  that  the  standard  of  service  will  be  kept  propor- 
tionate to  the  economic  conditions  which  give  the  value  to  a  dollar. 

4.  Employees  honorably  retired  from  service  may  hold  their 
10  per  cent  stock  during  lifetime,  and  the  principal  will  be  paid 
to  their  heirs. 

5.  The  appointment  of  the  Acting  Professional  Sta£F  shall  be 
annual,  by  a  merit  system. 

6.  The  members  of  the  Acting  Professional  Staff  shall  retire  to 
the  Consulting  Staff  at  forty-five. 

7.  Any  member  of  the  Staff  or  Acting  Staff  may  loan,  at  5  per 
cent,  money  for  equipment  which  he  especially  desires,  provided 
the  loan  is  made  for  at  least  five  years. 

8.  Any  member  of  the  Staff  or  any  Employee  may  withdraw 
his  loan  at  any  time,  and  it  shall  be  automatically  withdrawn,  if  he 
is  superseded,  discharged,  or  resigns  except  as  provided  in  Section  4. 

9.  The  charter  of  incorporation  may  be  revoked,  if  at  any  time 
it  cannot  be  shown  that  at  least  100  subscribers  are  ready  to  advance 
loans  of  $1,000  at  5  per  cent.  (This  is  to  insure  starting  business 
again  in  case  of  adverse  legal  decision.) 

10.  Any  physician  or  surgeon  registered  in  Massachusetts  may 
treat  suitable  cases  at  the  Hospital  with  the  same  privileges  as  the 
Staff,  provided  the  conditions  of  the  End  Result  Report  are  com- 
plied with. 

11.  Such  other  articles  as  the  incorporators  deem  necessary  to 
insure  the  proper  management  and  usefulness  of  the  Institution. 

It  will  be  seen  that  if  the  provisions  of  these  articles  are  obserred, 
the  following  advantages  will  be  obtained: 

1.  There  will  be  no  opportunity  for  any  employee  or  any  mem- 
ber of  the  Staff  to  grow  rich  at  the  expense  of  the  patients. 

2.  Persons  of  medium  circumstances  will  always  be  able  to 
obtain  Standard  Hospital  Care  and  Standard  Professional  Service 
in  proportion  to  the  economic  value  of  a  dollar.  There  will  be  no 
Charity  except  in  the  way  we  all  treat  one  another.  (See  reference, 
"The  Dividing  Line  between  Medical  Charity  and  Medical  Busi- 
ness."   By  E.  A.  C.) 

3.  Employees  can  raise  their  salary  by  borrowing  at  a  lower 
rate  and  loaning  to  the  Hospital  at  10  per  cent.  This  will  give  them 
an  interest  in  the  institution  and  assure  them  of  a  pension  when 

167 


honorably  retired.     It  will  also  allow  them  to  invest  their  savings 
at  10  per  cent. 

4.  The  medical  profession  can  be  standardized,  so  that  those 
who  ask  larger  fees  can  organize  to  give  better  service,  or  others 
can  organize  at  a  lower  standard,  and  the  Charitable  Hospitals  can 
take  care  of  the  rest. 

5.  The  legacies,  which  former  pioneers  who  have  made  standard 
operations  and  other  forms  of  treatment  possible,  will  be  given  to 
the  people,  by  making  such  safe  operations  as  those  for  hernia  and 
appendicitis  purchascable  at  reasonable  prices. 

6.  The  true  pioneers  of  this  generation  will  have  honor,  and 
can  demand  recompense  for  treating  the  cases  which  this  Hospital 
refuses  as  too  experimental  for  business. 

7.  The  rich  will  find  our  Reports  directories  to  enable  them  to 
select  surgeons  or  physicians  as  particularly  competent,  because 
we  have  referred  our  difficult  cases  to  them,  and  our  Reports  show 
that  they  have  been  relieved. 

8.  Our  End  Result  Report  will  show  the  public  how  far  scien- 
tific medicine  has  become  practical. 

9.  Surgeons  not  on  our  Staff,  who  believe  in  some  unusual  oper- 
ation which  they  recommend,  can  select  favorable  cases,  operate  on 
them  here,  and  thus  demonstrate  to  the  Public,  under  our  authority, 
the  value  of  their  ideas. 

10.  Patients  who  question  their  surgeon's  sincerity,  can  insist 
upon  putting  their  cases  on  record  here,  by  asking  him  to  operate 
here,  or  by  spending  a  few  days  with  us  before  being  operated  on. 

11.  The  Acting  Surgeons  of  this  hospital  will  have  records 
established  of  what  their  experience  has  been. 

12.  E.  A.  C.'s  salary  can  never  be  any  more  than  what  the  other 
members  of  the  Staff  choose  to  allow  him  from  the  Professional 
Fees,  after  paying  the  hospital  expenses  and  interest.  Like  the 
other  members  of  the  Staff,  he  can,  however,  earn  money  outside 
of  the  hospital  from  patients  who  wish  to  retain  his  professional 
services  apart  from  those  of  the  rest  of  the  Staff. 

13.  Although  E.  A.  C.  guarantees  the  loans  and  their  interest 
from  failure,  the  existence  of  a  large  number  of  proffered  loans 
guarantees  E.  A.  C.  that,  whenever  the  business  justifies  it,  there 
is  always  plenty  more  money  to  invest  in  the  Hospital  or  Profes- 
sional equipment. 

14.  The  question  of  this  hospital's  existence  is  therefore  put  up 
to  the  Public.  If  they  want  "a  hundred  dollar  hospital  with  a 
hundred  dollar  staff,"  they  can  have  it.  When  our  ten  beds  stay 
full,  we  shall  add  more,  but  never  shall  increase  our  investment 
faster  than  income,  nor  increase  our  business  so  fast  that  we  cannot 
take  time  to  trace  the  results. 

Those  who  loan  to  this  hospital,  loan  to  the  End  Result  Idea. 
Their  only  risk  is  from  E.  A.  C.'s  inability  to  put  the  plan  through. 
And  their  investment  is  guaranteed  by  his  entire  personal  property. 

168 


No  idea  of  charity  is  to  be  associated  with  this  enterprise.  It  is 
a  matter  of  business,  not  of  philanthropy,  except  in  so  far  as  it  will 
drive  Business  out  of  the  Charitable  Hospitals,  so  that  their  funds 
can  be  devoted  to  the  sick  poor  of  this  generation,  and  to  the  pre- 
vention of  sickness  in  all  classes  in  the  next  generation. 

Institutions  from  Which  I  Should  Be  Glad  to  Accept 
Proffered  Loans 

1.  The  Massachusetts  General  Hospital,  because  the  success 
of  my  hospital  would  relieve  that  institution  of  any  obligation  to 
use  its  funds  for  the  care  of  the  curable,  wage-earning  classes.  It 
could  then  devote  some  of  its  funds  to  determining  and  increasing 
the  degree  of  its  efficiency  in  treating  the  incurable  and  the  poor. 
It  could  use  its  new  private  ward  for  the  very  rich,  who  could  get 
the  benefit  of  the  services  of  the  same  Staff  which  it  honors  with 
appointments  to  treat  the  very  poor,  and  the  difficult  and  obscure 
cases  in  all  classes  of  society. 

2.  Harvard  University,  because  the  End  Result  System  would 
enable  her  to  teach  her  students  the  difference  between  curable  cases, 
suitable  for  them  to  accept,  and  difficult,  obscure,  or  incurable 
cases,  which  should  be  referred  to  others.  It  would  also  enable  her 
to  select  for  instructors  or  to  retain  as  instructors  men  who  can  and 
do  teach  the  relief  of  disease  by  example  rather  than  by  precept. 

3.  The  American  College  of  Surgeons,  because  the  example  of 
this  hospital  would  help  them  in  their  program  to  clean  up  the  abuses 
of  Modern  Surgery. 

4.  The  American  Medical  Association. 

5.  The  American  Hospital  Association. 

6.  The  American  Association  for  the  Control  of  Cancer. 

7.  All  other  associations  for  the  Promotion  of  Health  or  the 
Elimination  of  Disease. 

How  Can  I  Obtain  a  Staff  of  Specialists? 

I  make  no  secret  of  it, —  I  have  tried  unsuccessfully  among  my 
friends  to  gather  a  Staff  who  will  do  as  I  do,  i.  e.,  undertake  to  treat 
only  such  cases  as  I  feel  I  am  qualified  to  treat;  and  if  I  make  a 
mistake,  and  do  not  succeed  in  relieving  the  patient,  to  report  the 
case,  as  I  have  in  this  volume.  P'or  instance,  I  want  an  obstetrician 
who  is  qualified,  after  making  a  prenatal  examination,  to  accept  for 
confinement  such  cases  as  will  run  a  normal  course  or  present  only 
minor  complications.  I  want  him  to  have  the  moral  courage  to  call 
in  for  cases  which  are  unusually  difficult  or  in  which  any  serious 
complication  occurs,  some  acknowledged  leader  in  obstetrics,  just 
as  I  have  called  in  Dr.  C.  A.  Porter  for  Cases  53  and  146.  Now 
where  can  I  get  a  man  who  has  such  judgment  as  this?  Even  if  our 
medical    schools    graduated   students    with    a   guarantee   of   having 

169 


demonstrated  such  ability  in  a  series  of  one  hundred  cases,  would 
such  a  man  be  willing  to  work  for  his  share  of  our  professional  fee? 

I  want  a  throat  specialist  to  do  routine  operations  for  tonsils, 
adenoids,  and  septums.  Such  operations  are  being  done  by  the 
hundred  at  our  Charitable  Hospitals.  They  are  not  very  difficult 
or  dangerous,  but  they  do  not  always  help  the  patient.  I  think  I 
could  do  them  myself.  But  I  do  not  think  I  can  tell  when  they  will 
do  good  and  when  they  will  not.  Where  can  I  find  a  specialist  who 
will  tell  me.''  Is  tliere  any  throat  specialist  who  has  a  record  of 
having  had  demonstrably  good  results  in  a  series  of  a  hundred  con- 
secutive operations  of  this  kind.^  Is  there  any  throat  clinic  which 
is  trying  to  graduate  assistants  with  such  a  record.''  I  will  go  even 
farther.  Is  there  any  throat  specialist  who  will  risk  his  reputation 
by  undertaking  to  operate  on  one  hundred  successive  routine  nose 
and  throat  operations  at  my  hospital.''  Reference  to  my  report  wiD 
show  that  Cases  2,  3,  193,  250,  320  had  operations  of  this  class  done 
by  tlie  two  best  specialists  I  know  in  Boston,  Dr.  D.  Crosby  Greene 
and  Dr.  J.  L.  Goodale.  The  operations  were  skillfully  done,  but 
in  only  one  case  did  they  result  perfectly,  I  can  get  Dr.  Greene  or 
Dr.  Goodale  to  operate  on  any  difficult  cases  I  want  to, — no  matter 
if  the  patient  cannot  pay.  They  are  "authorities"  and  they  must 
do  it,  if  I  call  them.  But  what  I  want  is  a  throat  specialist  who  is 
not  an  authority,  who  will  only  do  the  simple  and  clearly  indicated 
operations.  When  such  a  man  has  been  on  the  Stafif  of  this  hos- 
pital for  about  five  years,  and  his  results  have  proved  his  ability 
to  use  this  amount  of  knowledge  and  judgment,  he  might  legitimately 
begin  to  pose  as  an  "authority"  himself! 

A  specialist  to  me  is  a  man  who  can  cure  kinds  of  cases  which 
I  cannot.  I  want  specialists  of  this  kind  to  join  my  hospital, — not 
"authorities"  in  the  various  specialties.  I  can  get  the  services  of 
"authorities"  for  nothing  for  my  poor  patients! 

In  the  same  way  I  want  all  sorts  of  specialists.  Here  is  the 
hospital  well-equipped,  and  I  am  ready  to  add  any  necessary  special 
equipment.  All  I  ask  is  that  each  specialist  shall  do  as  I  do  and 
be  ready  to  take  whatever  discredit  may  come  from  the  failure  of 
his  best  efforts. 

Surely  there  must  be  men  who  dare  to  compete  with  the  vested 
interests  in  Boston  Medical  Circles.  Is  there  no  one  else  who  can 
see  tliat  Harvard  and  all  other  Medical  Schools  are  teaching  in  the 
wrong  way.''  Perhaps  some  specialists  who  are  ready  to  retire  from 
competitive  practice  as  "authorities"  will  be  willing  to  sink  with 
me  into  the  second  class,  and  refer  their  difficult  cases  to  others. 
Had  we  not  better  perish  in  this  way  by  admitting  that  more  and 
more  cases  had  better  be  cared  for  by  others  than  to  continue  to 
carry  the  "authority"  and  "experience"  bluff  to  the  same  disastrous 
limit  that  we  have  seen  our  seniors  carry  it?  If  our  experience 
counts  for  anything,  it  should  enable  us  to  make  good  in  our  selec- 

170 


tion  of  cases.  When  we  refuse,  and  the  younger  specialist,  who  has 
more  time  and  energy  for  study,  succeeds,  it  will  then  be  clearly 
to  his  credit. 

The  truth  is,  that  I  am  trying  to  find  the  place  where  the  end 
of  the  rainbow  touches  the  ground.  A  specialist  who  can  select  cases 
which  he  can  relieve  is  harder  to  find  than  an  "authority."  Every 
specialist  becomes  an  "authority"  as  soon  as  you  or  I  call  him. 
But  if  I  found  a  specialist  who  could  select  relievable  cases,  he  would 
soon  become  a  real  "authority,"  and  his  business  would  increase  so 
rapidly,  that  he  could  not  afford  to  work  for  his  share  of  our 
Professional  Fee.  I  have  to  be  constantly  on  guard  against  becom- 
ing an  authority  myself,  and  often  have  difficulty  in  convincing 
patients  that  I  am  not.  If  I  were  appointed  as  the  head  of  a  Clinic 
at  a  Charitable  Hospital,  I  could  not  get  out  of  it !  Having  publicly 
expressed  the  opinions  I  have,  the  Trustees  could  hold  me  to  giving 
my  personal  care  to  the  doubtful  and  difficult  cases,  and  to  thus 
allowing  my  subordinates  to  establish  records  for  efficiency  in  the 
easier  cases. 

Every  colleague  who  joins  this  Hospital  Staff  should  take  this 
same  attitude.  A  Charitable  Hospital  appointment  must  mean  an 
honor,  not  a  privilege  or  a  sinecure.  The  Charitable  Hospital 
appointment  should  mean  a  fair  exchange.  It  should  be  clearly 
understood  that  honor  and  opportunity  must  be  paid  for  by  respon- 
sibility and  service. 

But  the  appointments  at  this  hospital  have  no  such  compensa- 
tions. Here  it  must  be  give  and  take,  in  work  and  money.  We  want 
no  pretense  of  charity.  We  sell  guaranteed  work  as  cheaply  as  is 
consistent  with  making  a  living.  We  must  set  fractures,  remove 
gallstones,  deliver  babies,  or  excise  tonsils,  in  return  for  money 
enough  to  pay  the  wages  of  our  skilled  labor,  not  our  "authoritiy." 
We  cannot  pay  our  Staff  with  honor  and  opportunity.  Not  at 
present ! 

Thus  it  is  not  difficult  to  see  why  my  friends  do  not  join  me 
in  this  enterprise.  They  can  take  less  responsibility,  receive  more 
honor  and  less  discredit,  as  well  as  make  more  money,  by  continuing 
to  play  their  roles  as  "authorities." 

How  different  is  my  position  from  that  of  Charitable  Hospital 
Trustees!  Their  clinic,  their  "material,"  their  privileges,  are  assets 
which  they  can  barter  for  service.  To  introduce  The  End  Result 
System,  all  they  would  have  to  do  would  be  to  pass  a  vote!  They 
can  put  Hospital  Humbug  asleep  forever  by  merely  insisting  on 
an  End  Result  Report!  Nevertheless,  in  spite  of  all  these  dis- 
advantages, I  propose  to  begin  my  new  organization  by  appointing 
the  best  Consulting  Staff  I  can  get  after  this  Report  has  been  pub- 
lished and  distributed  to  every  member  of  the  American  College  of 
Surgeons  and  every  member  of  the  Massachusetts  Medical  Society. 

I  shall  pick  the  best  Consulting  Staff  I  can,  adding  one  by  one, 
so  that  each  one  elected  may  vote  for  the  next. 

171 


I  am  -well  aware  that  it  will  be  difficult  to  find  men  who  will 
be  conscientious  enough  to  accept  this  position  and  yet  forceful 
enough  to  dare  to  do  it.  Such  men  will  be  able  to  earn  large  incomes 
without  association  with  such  an  outlaw  institution  as  this  which 
stoops  to  advertising,  "No  cure,  no  pay,"  "Results  guaranteed," 
and  "Payment  on  the  instalment  plan."  But  still  I  shall  find  some 
men  who  will  do  it. 

Duties  of  the  Consulting  Staff 

1.  The  Consulting  Staff  will  assist  Dr.  Codman  and  the  Acting 
Staff  to  treat  unusual  or  difficult  cases. 

2.  They  will  aid  Dr.  Codman  to  select  for  appointment  an 
Acting  Staff  of  specialists.  Appointments  to  the  Acting  Staff  will 
be  made  annually  on  a  merit  system,  chief  consideration  being  given 
to  what  the  Consulting  Staff  considers  the  best  piece  of  work  that 
has  been  done  in  this  vicinity  in  each  specialty. 

3.  They  will  advise  Dr.  Codman  about  the  management  and 
policies  of  the  hospital. 

A  Staff  Which  Is  Sought — Not  One  Which  Is  Seeking 

I  shall  seek  the  help  of  this  Consulting  Staff,  because  I  believe 
that  they  can  help  me  to  make  a  smaller  percentage  of  errors  in  my 
own  cases,  and  because  they  will  increase  the  number  of  kinds  of 
cases  which  this  institution  can  successfully  treat.  I  am  not  going 
to  take  advantage  of  their  reputations  to  ask  them  to  treat  cases 
which  will  probably  turn  out  badly.  I  seek  their  help  in  treating 
cases  which  will  come  out  well,  and  I  rely  on  their  experience  and 
judgment  to  enable  them  to  choose  such  cases;  and  in  the  event  of 
failure,  to  confess,  as  I  have  in  Part  I,  what  the  cause  of  the  failure 
was.  We  shall  then  act  accordingly, —  perhaps  new  equipment  will 
be  needed,  perhaps  better  nursing,  perhaps  a  new  member  on  the 
Staff  to  do  something  which  none  of  us  know  how  to  do. 

Perhaps  a  doubtful  case  will  turn  up  which  none  of  us  feels  is 
likely  to  be  successful.  We  can  either  refer  such  a  case  to  a  Pro- 
fessor of  Surgery  at  one  of  our  Medical  Schools,  to  a  Chief  of  Service 
at  one  of  the  Charitable  Hospitals,  or  to  some  individual  surgeon 
to  whom  some  Charitable  Hospital  has  assigned  such  cases  for 
special  study,  or  any  of  us  may  take  him  to  some  private  hospital 
and  operate  on  him  there  (in  which  case,  as  is  usual  in  our  present 
practice,  the  result  of  the  experiment  will  never  be  known,  unless 
he  has  first  entered  here). 

By  and  by  there  will  come  a  time  when  we  shall  have  to  admit 
that  we  cannot  do  certain  special  operations  well  enough  to  take 
the  business  risk  on  them.  For  instance,  the  technique  of  trans- 
fusion, especially  the  hemolysis  test,  is  difficult  for  me  to  do,  now 
that  I  have  few  opportunities.  I  have  to  seek  this  service  from 
others  who  are  having  constant  practice.     Obviously  it  would  be 

172 


better  business  for  a  member  of  our  Staff  to  obtain  an  opportunity 
at  one  of  the  Charitable  Hospitals  to  perfect  himself  in  this  tech- 
nique, but  that  would  be  changing  the  positions, — he  would  be 
seeking  the  opportunity  to  practice. 

And  this  is  what  positions  on  the  Staffs  of  Charitable  Hospitals 
are  held  for;  men  seek  them  instead  of  being  sought  for  them. 
Trustees  feign  to  appoint  the  best  man  they  can  get  from  those 
who  apply.  They  do  not  seek  competent  men  to  make  sure  of  a  good 
result,  but  men  who  want  practice,  so  that  they  can  become  compe- 
tent. At  this  hospital  we  shall  have  the  reverse  condition:  We  seek 
to  make  sure  of  a  good  result,  not  merely  an  opportunity  to  experi- 
ment, or  practice  technique. 

This  policy  of  waiting  for  applicants  for  positions  saves  the 
Trustees  no  end  of  trouble,  for  by  making  a  pretense  to  secure 
"the  best  surgeon  available,"  they  are  able  to  keep  the  balance  of 
power  in  their  hands.  If,  instead  of  making  a  pretense,  they  actu- 
ally did  seek  the  best  man  available,  it  would  turn  the  tables  and 
put  the  power  into  the  hands  of  the  medical  profession.  The  one 
who  is  sought  makes  the  best  of  most  bargains.  I  say  "a  pretense," 
because  in  this  Community,  year  after  year,  appointments  are  made 
on  a  Seniority  basis,  and  such  a  fact  is  incompatible  with  the  devel- 
opment of  modern  Medical  Science.  It  denies  that  study,  effort, 
conscientious  care,  and  natural  qualifications  can  make  one  individual 
surpass  another  in  his  ability  to  relieve  and  cure  symptoms  due  to 
definite  pathologic  conditions. 

The  Result  of  this  Trustees'  Pretense  of  seeking  (and  in  reality 
of  saving  their  institutions  trouble  and  expense)  is  one  cause  of  the 
present  pitiable  fact  that  the  greater  portion  of  the  Community  is 
treated  in  our  Charitable  Institutions.  The  doctors  are  paid  nothing 
except  in  the  opportunity  to  even  up  by  taking  exorbitant  amounts 
from  private  patients.  And  those  patients  who  pay  must  get  just  as 
little  as  the  poorest  do,  because  when  Hypocrisy  reigns  fer  two- 
thirds  in  the  hospital  work,  it  cannot  break  the  habit  for  the  other 
third. 

Certainly  in  this  Community  the  time  is  nearly  at  hand  when 
the  worm  will  turn.  The  doctors  are  spending  such  a  large  propor- 
tion of  their  time  at  the  Charitable  Hospitals,  without  other  pay 
than  the  opportunity  to  experiment  and  make  reputations,  and  the 
Charitable  Hospitals  are  outbidding  each  other  so  fast  in  what  they 
give  away  ($3.50  to  $4.48  per  patient  day),  that  presently  there 
will  be  no  public  left  to  whom  the  doctors  may  sell  the  individual 
experience  and  skill  gained  by  their  hospital  experiments  and 
practice. 

Did  you  ever  think  what  the  Trustees  of  our  Hospitals  would 
do  in  case  of  a  strike  by  the  medical  profession? 

They  would  Seek  instead  of  being  Sought. 

Moreover,  if  the  plan  of  this  hospital  were  carried  out  in  other 
hospitals,  they  would  know  whom  to  seek  for  each  class  of  cases. 

173 


Thev  might  have  to  pay  salaries  for  men  to  work  on  the  difficult 
cases. 

But  the  use  of  Charitable  funds  to  pay  a  professional  staff  is 
legitimate,  and  furthermore,  it  would  exact  a  sense  of  responsibility 
for  End  Results. 

Cases  are  now  neglected  at  Charitable  Hospitals  largely  because 
of  this  idea  that  hospitals  should  get  their  professional  service  for 
nothing.  This  false  Charity  runs  through  the  whole  profession, 
beginning  with  the  student  who  gets  his  education  by  means  of  it. 

Cutting  Prices  or  Raising  Prices? 

Suppose  the  plan  we  have  indicated  should  go  through,  and 
this  hospital  should  succeed  in  establishing  itself  as  a  standard, — 
a  Hundred  Dollar  Hospital  with  a  Hundred  Dollar  Staff. 

Would  it  lower  or  raise  professional  charges?  By  some  I  shall 
be  accused  of  a  malign  attempt  to  cut  down  surgeons'  incomes.  By 
others  I  shall  be  accused  of  demanding  that  Trustees  use  a  part 
of  their  funds  to  pay  for  professional  service  to  their  patients,  and 
thus  deprive  the  sick  poor  of  their  comforts.  I  shall  be  accused  of 
wanting  to  annihilate  the  isolated  specialist's  income  and  of  making 
a  plutocrat  of  the  general  practitioner.  The  truth  is,  I  do  recom- 
mend cutting  down  a  few  surgeons'  incomes ;  I  do  recommend  the 
elimination  of  specialists  who  are  specialists  by  name  rather  than 
by  achievement;  and  I  do  recommend  putting  a  premium  on  the 
practitioner  who  is  an  honest  friend  and  adviser  of  his  patient. 

Above  all,  I  do  recommend  teaching  the  Public  to  distinguish 
three  different  qualifications  in  doctors  for  which  they  must  pay  in 
different  ways: 

1.  The  personal  qualities  of  charm  and  sympathetic  optimism 
which  give  transient  mental  comfort  to  the  patient  and  for  which 
the  history  of  human  nature  shows  him  ready  to  pay. 

2.  The  impersonal,  efficient,  skillful,  thorough  treatment  of  an 
organized  group  of  specialists,  who  in  a  businesslike  way  give  him 
the  benefit  of  the  truths  hitherto  acquired  by  medical  science.  The 
rise  of  the  modern  isolated  specialist  proves  that  the  Public  is  ready 
to  pay  for  this. 

3.  The  ultra-educated,  genius-like  minds,  who  have  the  appli- 
cation and  ability  to  wrest  from  the  unknown  the  secrets  which  can 
be  taught  to  the  average  intelligence.  It  is  these  men  whom  our 
universities  now  ask  to  teach  the  truth  to  their  students,  on  the  one 
hand,  and  to  make  their  living  by  taking  advantage  of  tlie  ignorance 
of  the  rich,  on  the  other.  They  should  be  well  paid  by  endowed 
institutions  for  fearlessly  telling  the  Truth.  The  recent  rapid  growth 
of  endowed  institutions,  such  as  the  Rockefeller  Institute  and  vari- 
ous hospitals,  shows  that  men  of  experience  in  organized  industry 
are  beginning  to  appreciate  the  value  of  original  minds. 

It  is  our  belief  that  in  founding  an  institution  on  the  End  Result 

174 


Idea  we  are  taking  our  part  in  the  natural  evolution  of  modern 
medicine.  We  shall  help  to  lower  those  prices  which  are  grossly 
unjust  and  to  raise  those  which  are  likewise  grossly  unjust. 

But,  in  any  event,  we  must  wait  on  the  education  of  the  Public. 
The  institution  is  started,  financed  enough  to  grow,  and  is  ready 
to  expand.  But  no  matter  how  great  the  capitalization,  it  can  grow 
no  faster  than  the  number  of  patients  who  are  willing  to  have  their 
cases  reported.  We  do  not  sell  Humbug,  so  the  question  is  whether 
there  is  a  demand  for  Honest  Medicine  and  Surgery. 

On  the  other  hand,  if  the  principles  involved  in  this  organization 
are  too  far  removed  from  what  is  called  Medical  Ethics,  the  Com- 
mittees on  Ethics  and  Discipline  of  the  Medical  Organizations  of 
which  the  writer  is  a  member  can  call  us  to  account.    (See  page  131.) 

If  these  organizations  let  us  live,  we  can  employ  the  recent 
graduates  of  such  hospitals  and  medical  schools  as  teach  their 
students,  by  example,  not  to  assume  responsibility  which  they  know 
they  are  not  fitted  to  imdertake. 

How  May  the  Young  Surgeon  Make  His  Start 

UNDER  THE   EnD    ReSULT   SySTEM  ? 

It  is  clear  from  what  I  have  just  said  that  I  should  like  to  employ 
a  young  surgeon  to  do  all  the  work  at  my  hospital  that  he  is  fitted 
to  do, — but  that  I  dp  not  want  to  give  him  a  chance  to  learn  surgery 
by  making  mistakes  on  my  patients.  I  shall  have  to  pay  an  assistant 
to  help  me,  for  I  must  fix  responsibility  on  him.  At  present,  at  the 
Charitable  Hospital,  he  is  usually  not  paid,  for  he  receives  his 
reward  in  the  opportunity  to  learn  by  his  own  mistakes.  He  has  the 
appearance  of  taking  responsibility,  but  is  not  really  held  account- 
able for  his  errors.  If  he  is  to  be  held  accountable,  he  should  be 
paid.  This  is  the  answer  to  the  question.  The  End  Result  System 
would  ultimately  oblige  Trustees  to  pay  for  much  of  their  profes- 
sional labor. 

Is  such  a  state  of  affairs  as  now  exists  necessary  at  the  Charitable 
Hospitals.''  Why  should  not  the  student  be  taught  what  to  do  and 
how  to  do  it,  before  being  allowed  to  do  it.^"  If  it  is  for  my  interest 
not  to  assign  responsibility  without  making  sure  that  the  person 
who  takes  it  is  competent,  why  should  it  not  be  the  duty  of  Trustees 
or  of  one  of  their  representatives .''  Is  it  not  possible  to  conceive  of  a 
charitable  hospital  which  makes  it  a  rule  not  to  accept  for  treatment 
any  cases  which  its  Staff  cannot  relieve.''  A  business  organization 
which  started  in  on  this  basis  would  insist  on  its  Staff  becoming 
competent,  or  it  would  seek  men  who  were  competent.  Who  could 
they  get,  but  men  who  had  been  trained  in  the  universities  and  larger 
hospitals?  At  present,  any  one  with  an  M.D.  will  do,  for  he  does 
not  have  to  be  competent. 

To  express  it  plainly, — if  the  End  Result  System  were  in 
common  use,  all  hospital  work  would  have  to  be  done  so  much  more 
thoroughly  than  it  is  today,  that  competent  assistants  would  be  in 

176 


great  demand.  There  would  be  more  work  to  be  done  by  the  young 
surgeon, — not  less  work.  If  the  chiefs  were  obliged  to  concentrate 
their  attention  on  the  difficult  cases,  they  would  be  glad  enough  to 
let  their  juniors  do  what  routine  operating  they  could  safely  intrust 
to  them. 

If  a  young  surgeon  devoted  his  time  and  brains  to  studying  some 
difficult  class  of  cases,  and  through  the  knowledge  thus  attained 
succeeded  in  developing  a  satisfactory  method  of  treatment,  his 
services  would  be  in  immediate  demand.  If  his  methods  were  really 
good,  they  would  be  advertised  in  the  End  Result  Report  of  his 
hospital.  Others  would  come  from  distant  hospitals  to  learn  from 
him.  His  work  would  be  a  credit  to  his  hospital  and  a  cause  for 
his  promotion.  Those  who  came  from  distant  hospitals  to  learn  his 
methods  would  establish  similar  reputations  locally,  when  they  re- 
turned to  their  communities.  The  result  of  this  would  be  a  constant 
process  of  the  rational  diffusion  of  new  and  successful  forms  of 
treatment,  instead  of  scattered  instances  of  experiments  performed 
by  individuals,  more  or  less  aimlessly,  and  without  adequate  record 
to  try  out  vaunted  discoveries. 

After  all,  there  is  a  certain  amount  of  operating  to  be  done, 
and  a  certain  number  of  men  to  do  it.  Therefore,  it  cannot  be  said 
that  the  young  surgeon  would  get  less  experience  if  the  system  of 
organization  of  our  hospitals  were  changed,  so  that  he  began  by 
doing  what  he  could  be  trusted  to  do  well.  We  should  soon  find  that 
we  should  get  better  results  by  permitting  him  to  do  much  of  the 
actual  operating,  than  by  intrusting  him  with  many  of  the  really 
difficult  and  important  details  of  pre-  and  post-operative  treatment, 
which  we  now  give  over  to  him  because  they  are  tedious,  time- 
consuming,  and  uninteresting. 

We  should  find,  as  is  shown  in  our  analysis  in  Part  I,  that  since 
our  failures  result  from  errors  of  care,  errors  of  skill,  errors  of 
knowledge,  errors  of  judgment,  and  from  our  inability  scientifically 
to  cope  with  some  of  the  diseases  which  affect  our  patients,  the 
young  surgeon's  education  should  be  developed  with  regard  to  these 
facts.  We  should  therefore  first  make  the  young  surgeon  qualify 
by  demonstrating  that  he  can  exhibit  constant  care  in  doing  what  he 
has  been  taught  how  to  do.  He  can  then  attain  skill  by  assisting, 
by  dissecting,  by  operating  on  animals,  and  by  doing  routine  opera- 
tions. He  can  acquire  knoxoledge  by  study,  travel,  observation,  and 
by  following  the  End  Results  of  cases  he  has  helped  to  operate  on, 
so  that  he  can  learn  by  his  superiors'  errors  as  well  as  by  their 
successes.  Judgment  must  come  from  experience,  as  well  as  from 
training  and  an  inborn  balance  of  mind.  If  the  young  surgeon  is 
permitted  to  record  his  differences  of  opinion  when  he  does  not 
agree  with  his  chief  or  his  colleagues,  his  judgment  can  be  actually 
measured.  It  will  be  found  to  be  a  more  accurate  test  of  judgment 
to  oblige  the  junior  to  select  tlie  cases  he  is  competent  to  relieve, 
than,  as  is  often  done  now, — to  assign  cases  to  him  as  a  reward  for 

176 


assisting  his  senior  in  private  practice !  Finally,  having  qualified  at 
these  tests,  if  he  has  the  ability  to  search  out  from  the  Unknown 
some  of  the  secrets  of  pathology,  and  to  found  successful  methods 
of  treatment  on  this  knowledge,  he  may  qualify  as  a  great  surgeon. 

Then  there  is  always  surgery  to  be  done  in  remote  communities 
and  in  the  poorer  districts,  and  now  there  is  the  war.  Shall  we  let 
a  Seniority  System  keep  returning  military  surgeons  at  arm's  length, 
as  it  does  the  surgeons  who  have  gone  to  remote  civil  fields.''  Or 
shall  we  make  the  counter  mistake  of  dropping  tried  civil  surgeons 
to  make  room  for  returning  military  heroes  ?  When  this  war  is  over, 
let  us  at  least  remember  the  lesson  that  Efficiency  in  Peace  is  the 
best  training  for  Efficiency  in  War. 

It  is  well  enough  to  believe  that  Right  makes  Might,  but  the 
corollary  is,  that  Might  is  a  proof  of  the  Efficient  use  of  Right. 
Truth  is  Right  and  Science  is  but  a  synonym  of  Truth.  Efficiency 
must  acknowledge  Truth  and  use  it  in  a  truthful  way.  It  is  the 
scientific  use  of  science.  There  is  nothing  evil  about  either  Efficiency 
or  Might.  The  Truthful  use  of  Truth  cannot  be  wrong.  That  indi- 
vidual, that  group,  that  hospital,  that  community,  that  nation,  that 
world,  which  plays  the  cleanest  game  will  be  the  mightiest  and  the 
happiest!  Individual  leaders  can  never  read  the  future  clearly 
enough  to  justify  their  employing  secrecy  to  increase  Efficiency. 
The  Few  need  the  help  of  the  Many  when  they  seek  such  a  difficult 
thing  to  obtain  as  Truth.  Secrecy  is  the  peculiar  disease  of  Efficiency. 
It  produces  suspicion  and  distrust  in  the  team  itself,  and  victory 
depends  on  the  superior  integrity  (in  both  senses  of  the  word)  of 
the  team.  Publicity  is  the  cure  of  the  disease,  Secrecy.  Publicity 
acknowledges  not  only  the  importance  of  Truth,  but  the  fact  that 
it  is  difficult  to  obtain,  even  when  we  all  earnestly  try  for  it.  It  is 
idle  to  say  that  we  have  not  already  much  Truth  at  our  disposal, 
but  it  can  be  said  that  we  should  find  more  Truthful  ways  in  which 
to  use  it. 


177 


ADVERTISEMENT 

CoDMAN  Hospital  Clinic,  15  Pinckney  St.,  Boston,  Mass. 
Tuesdays,  Thursdays,  and  Saturdays  at  12  o'clock 


MAXIMUM  FEES 

(Half  of  which  will  be  used  to  maintain  the  Hospital  and  Clinic, 

and  the  other  half  divided  among  the  Professional  Staff) 

Physical  examination,  diagnosis,  and  advice $10.00 

X-ray    examination 10.00 

Later  office  visits  for  advice  or  treatment 3.00 

Calls  at  patients'  homes 5.00 

(and  $3  an  hour  after  first  hour) 

Consultation  with  patient's  physician  at  home 10.00 

(and  $10  for  each  additional  hour) 
Care   in    Hospital    (including  operation   and   other   professional 
services  of  Staff) 

For  first  weeli 100.00 

For  each  week  thereafter 60.00 

General  Anaesthetic 10.00 

Operations  at  patients'  homes  or  at  other  liospitals  .  No  fixed  charges 


MINIMUM  FEES 
(For  patients  who  claim  inability  to  pay  the  above) 

One-half  the   above  amounts    (all  used  to  maintain  the  Hospital  and 
Clinic). 


Half  the  maximum  fee  may  be  paid  on  the  instalment  plan,  but  one-half 
must  be  paid  in  cash,  weelily  in  advance. 

All  Fees  will  be  returned  if  at  the  end  of  a  year  the  patient  claims  he 
was  not  benefited. 

All  patients  must  be  willing  to  have  the  record  of  their  cases  made  public 
by  number  (not  by  name). 

Any  patient  may  consult  Dr.  Codman  or  any  member  of  the  Staff 
privately,  without  having  his  case  put  on  record  at  the  Hospital.  In  such 
cases,  the  charge  will  he  the  same  as  if  the  patient  consulted  the  Hospital 
and  had  the  benefit  of  the  advice  of  several  members  of  the  Staff. 

At  the  Hospital,  Dr.  Codman  will  see  every  patient  and  do  every  opera- 
tion if  the  patient  wisiies,  but  will  refer  to  his  colleagues  and  assistants 
all  steps  in  the  work  which  he  knows  they  are  as  competent  or  more  com- 
petent to  do. 

The  Clinic  will  not  undertake  to  treat  patients,  if  in  doubt  of  the  diag- 
nosis or  of  the  probability  of  the  success  of  treatment,  but  any  member 
of  the  Staff  may  do  so  privately — just  like  any  other  doctor. 


178 


LAST   WORD 


IF  MEDICAL  ETHICS  SHOULD  CRITICIZE 

US,  WOULD  THE  CRITICISMS  REFER 

TO  THE  PORTIONS  OF  OUR 

WORK  WHICH  WE  DO 

On  Tuesdays,  Thursdays,  and  Saturdays 
AT  THIS  HOSPITAL 

Where  we  treat  cases  which  our  experience 
has  qualified  us  to  relieve,  and  where  we 
advertise  (enlighten  the  Public)  as  to  what 
we  can  and  cannot  do. 


OB 


On  Mondays,  Wednesdays,  and  Fridays 

AT  PUBLIC  OR  PRIVATE  HOSPITALS 

Where  we  do  not  have  to  prove  that  we  are 
qualified  to  treat  the  cases,  and  where  we 
do  not  advertise  (enlighten  the  Public)  as  to 
what  we  can  and  cannot  do. 


179 


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